Post Anesthetic Recovery

Question 1

Airway Obstruction

Answer 1

The most common airway complication in the recovery room is the tongue lying against the posterior pharynx

The placement of an OPA, chin lift, or turning the patient on their side will help to alleviate this

Question 2

Laryngospasm

Answer 2

Laryngospasm may be cause through irritation (blood or mucous) in the oral pharynx

Suctioning can be used to remove this irritant

Question 3

Hypoventilation Due to Pain

Answer 3

Splinting of a painful chest or abdominal wounds may lead to hypoventilation

This can be compounded by narcotic analgesics which should be titrated to effect

Question 4

objective of narcotic pain analgesics

Answer 4

achieve pain relief without causing respiratory depression

If we overshoot we may need to give Narcan in order to reverse the narcotic

Question 5

Hypoventilation Due to Muscle Relaxants

Answer 5

When a non-depolarizing muscle relaxant is used, reversal can be aided with neostigmine and atropine

If hypoventilation continues to persist we will need to consider re intubation and ventilation until muscle function returns to normal

When a depolarizinf muscle relaxant is used airway maintenance (ETT, OPA, etc), ventilation, and time will help to solve the problem

Patient with atypical or low pseudo cholinesterase may require a longer period of time to reverse naturally

Question 6

Hypoxemia in Post Anesthetic Recovery

Answer 6

The first response is to increase the FiO2and correct the cause of hypoxemia (hypoventilation, nitrous oxide, washout)

When there is V/Q mismatching the use of bronchial hygiene and/or lung expansion should be used

Question 7

Pulmonary Edema in Post Anesthetic Recovery

Answer 7

Pulmonary edema may require O2, diuretics and inotropes.

Question 8

Hypertension in PARR

Answer 8

Many patient who have a previous history will have a BP problem in the PARR

Causes of high BP include increased ICP (serious sign), pain, full bladder, hypercapnia, hypoxemia, and fluid overload

Treatment for hypertension includes blood pressure reducing agents and these should be given immediately

Question 9

Nausea and Vomiting

Answer 9

Extremely common complaint in the PARR

Recovery position will help to reduce the chance of aspiration

Question 10

Nausea and Vomitting May be Caused By

Answer 10

Narcotic agents

Inhaled agents

Any situation where blood has been swallowed

Air in the stomach from NG tube

Question 11

Ondansetron

Answer 11

A serotonin 5-HT3receptor antagonist used as an antiemetic following chemotherapy or surgery

Will effect both peripheral and central nerves

Will reduce the activity of the Vagus nerve, which will activate the vomiting center in the medulla

Block the serotonin receptor in the chemoreceptor trigger zone

Will not affect vomiting that is caused through motion sickness

No effect on dopamine or muscarinic receptors

Question 12

Which of the following is NOTa consequence of overfeeding?

a) Hyperglycemia which leads to hyperinsulinemia
b) Increased carbon dioxide production
c) Hepatic lipolysis
d) Increased oxygen consumption

Answer 12

c) Hepatic lipolysis

Question 13

Nutrition in PARR

Answer 13

Careful monitoring of metabolic needs is mandatory as overfeeding is quite possible

The goal is to provide nutritional support in order to prevent starvation and help with the overall disease process

Given the complexity of the body’s metabolic response to injury, surgery, and stress; it is often difficult to predict the metabolic needs of the patient.

Question 14

Malnutrition

Answer 14

Malnutrition is associated with increased morbidity and mortality

Question 15

Overfeeding

Answer 15

Overfeeding can negatively impact the patient’s recovery process

Overfeeding will result in the provision of calories and protein in excess of patient needs

Question 16

Potential hazards of overfeeding includes

Answer 16

Hyperglycemia and resultant hyperinsulinemia

Hypertriglyceridemia

Respiratory insufficiency from increased carbon dioxide production

Liver function abnormalities

Azotemia

Immunosuppression.

Increased oxygen consumption due to a consequence of energy utilization

Hepatic lipogenesis, not lipolysis, results from overfeeding

Question 17

Restlessness and Excitement

Answer 17

Severity will range from mild discomfort to full psychomotor disturbances requiring staff to initiate patient restraints

Discomfort may result from prolonged positioning that requires re-positioning of the patient

Narcotic titration can be used to relieve (not just reduce) pain.

A full bladder can produce unbearable pain and/or discomfort

Ketamine recovery requires a low stimulatory room.

Assure normal oxygen levels.

Question 18

Heat Loss

Answer 18

Maintaining ideal body temperature is difficult in the OR and hypothermia and shivering is very common in PARR.

One cause is the drop of core temperature during surgery.

Open thoracic surgery can drop core temp dramatically.

Inhaled gases and infused fluids can be warmed to reduce this complication.

Question 19

Shivering

Answer 19

The loss of cortical inhibitors of the spinal reflex during recovery may result in shivering

Shivering causes an increase in oxygen demand and an increase in CO2production

Patients still experiencing some level of respiratory depression from anesthesia, may be ill-equipped to deal with the added stress this increase creates.

Patients who are shivering in PARR should be given blankets (or direct heat) and supplemental oxygen.

Question 20

Uncontrolled Pain Management

Answer 20

Uncontrolled (or under-controlled) pain may cause severe complications in the recovering patient.

These complications range from an increased hospital stays (prolonged wound healing) to severe negative outcomes including death.

Pain management is possible without the fear of future addictions

Under treatment is also unethical and immoral

Question 21

Methods of Pain Management

Answer 21

Analgesics can be given IV or IM during or after the procedure, and can be given orally during the recovery period.

Avoid restrictive bandages.

Support extremities that have been operated on to allow good drainage.

Have the patient use a large pillow, ‘Teddy’ or specialized abdominal wrap to facilitate coughing and deep breathing exercises.

Question 22

Clinical Controlled Pain Injections

Answer 22

Dose requirements to relieve post-operative pain have been based on body weight, which does not take into consideration the procedure or the individual pain threshold

The period between injection may be 3-4 hours and procedures like physio and position changes may be poorly coordinated with the injections

Question 23

Continuous Infusion

Answer 23

Continuous infusion may not control the breakthrough pain and may be more than needed when sedated or sleeping even when set at ¼ of expected need

Question 24

Patient Controlled analgesia can help eliminate

Answer 24

Nursing delays

Over and under pain control

Respiratory side effects of loading doses every 4 hours

Question 25

Patient Controlled Analgesia Dosages

Answer 25

The small dosages and lockout time period will allow the flexibility and control that is needed to control the pain intelligently

The maximum dose per 1-4 intervals can eliminate the worry of overuse

Question 26

Advantage of Patient Controlled Analgesia

Answer 26

Rapid onset —IV access

Eliminates wide serum fluctuations and side effects

Accommodates wide variability in pt need

Accommodates changing need as time passes

Pts benefit psychologically with the ‘control’

Avoids painful, problematic injections

Improves human relations with healthcare workers

Recovery time may well be shortened.