Post Anesthetic Recovery Flashcards
Airway Obstruction
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
Laryngospasm
Laryngospasm may be cause through irritation (blood or mucous) in the oral pharynx
Suctioning can be used to remove this irritant
Hypoventilation Due to Pain
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
objective of narcotic pain analgesics
achieve pain relief without causing respiratory depression
If we overshoot we may need to give Narcan in order to reverse the narcotic
Hypoventilation Due to Muscle Relaxants
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
Hypoxemia in Post Anesthetic Recovery
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
Pulmonary Edema in Post Anesthetic Recovery
Pulmonary edema may require O2, diuretics and inotropes.
Hypertension in PARR
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
Nausea and Vomiting
Extremely common complaint in the PARR
Recovery position will help to reduce the chance of aspiration
Nausea and Vomitting May be Caused By
Narcotic agents
Inhaled agents
Any situation where blood has been swallowed
Air in the stomach from NG tube
Ondansetron
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
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
c) Hepatic lipolysis
Nutrition in PARR
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.
Malnutrition
Malnutrition is associated with increased morbidity and mortality
Overfeeding
Overfeeding can negatively impact the patient’s recovery process
Overfeeding will result in the provision of calories and protein in excess of patient needs
Potential hazards of overfeeding includes
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
Restlessness and Excitement
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.
Heat Loss
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.
Shivering
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.
Uncontrolled Pain Management
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
Methods of Pain Management
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.
Clinical Controlled Pain Injections
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
Continuous Infusion
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
Patient Controlled analgesia can help eliminate
Nursing delays
Over and under pain control
Respiratory side effects of loading doses every 4 hours
Patient Controlled Analgesia Dosages
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
Advantage of Patient Controlled Analgesia
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.
