Postanesthesia Care (based on Morgan) Flashcards
Formerly anesthetized patients should not leave the operating room unless they have a patent airway, have adequate ventilation and oxygenation, and are hemodynamically stable; qualified anesthesia personnel must also be available to attend the transfer.
True
Before the recovering patient is fully responsive, pain is often manifested as postoperative restlessness. What are some serious systemic disturbances that must be considered in the differential diagnosis of postoperative agitation?
Hypoxemia, respiratory or metabolic acidosis, or hypotension
Intense shivering causes precipitous rises in oxygen consumption, CO2 production, and cardiac output. These physiological effects are often poorly tolerated by patients with what condition?
Preexisting cardiac or pulmonary impairment
Respiratory problems are the most frequently encountered serious complications in the postanesthesia care unit (PACU). What are the most common causes?
Airway obstruction, hypoventilation, and/or hypoxemia
Hypoventilation in the PACU is most commonly due to what?
Residual depressant effects of anesthetic agents on respiratory drive
Obtundation, circulatory depression, or severe acidosis (arterial blood pH < 7.15) indicates what kind of intervention?
Immediate and aggressive respiratory and hemodynamic intervention, including airway and inotropic support
Following naloxone administration, what should be closely monitored in patients?
Recurrence of opioid-induced respiratory depression (‘renarcotization’) due to naloxone’s shorter duration compared to opioids
Increased intrapulmonary shunting from a decreased functional residual capacity relative to closing capacity is the most common cause of what post-anesthesia condition?
Hypoxemia following general anesthesia
What surgical complications should be considered following central line placement, intercostal blocks, and certain abdominal or chest trauma procedures?
Postoperative pneumothorax
What is the most common cause of hypotension in the PACU?
Hypovolemia
What typically causes postoperative hypertension in the PACU?
Noxious stimulation from incisional pain, endotracheal intubation, or bladder distention
Why was specialized nursing care emphasized in the immediate postoperative period after World War II?
Many early postoperative deaths occurred immediately after anesthesia and surgery, and many were preventable. A nursing shortage and experience treating large numbers of battle casualties contributed to the trend of centralization in recovery rooms.
What percentage of all surgical procedures in the United States are now performed on an outpatient basis?
More than 70%
What is the difference between Phase 1 and Phase 2 recovery in outpatient surgery?
Phase 1 is the immediate intensive care recovery, and Phase 2 is a lower-level care for readiness to go home
How must the PACU be equipped to handle patients undergoing procedures such as central line placement, electroconvulsive therapy, and elective cardioversion?
It must be appropriately staffed and equipped to manage these patients and their potential complications.
Why should the PACU be located near operating rooms and off-site invasive procedure areas?
To ensure quick access in case patients need urgent surgery or care
Which equipment is mandatory in every PACU patient space?
Pulse oximetry, electrocardiogram, and automated noninvasive blood pressure monitors
Why is the PACU required to have its own supplies of emergency equipment?
To manage potential complications during the recovery of surgical patients
What kind of staff is required for the PACU?
Nurses specifically trained in anesthesia recovery, airway management, advanced cardiac life support, and common postoperative issues
What is the general ratio of recovery nurses to patients in a high-volume surgical institution PACU?
One recovery nurse for two patients
Which medical professionals are involved in the coordinated management of PACU patients?
Anesthesiologists, surgeons, nurses, respiratory therapists, and appropriate consultants
How does the use of a Bispectral Index Scale (BIS) monitor impact recovery?
It may reduce total drug dosage and shorten recovery time
What is the most frequent cause of delayed emergence from general anesthesia?
Residual anesthetic, sedative, and analgesic drug effects
How is delayed emergence treated in cases of opioid or benzodiazepine overdose?
Naloxone (for opioids) and flumazenil (for benzodiazepines)
What uncommon causes of delayed emergence should be considered?
Hypothermia, metabolic disturbances, and perioperative stroke
How should formerly anesthetized patients be transported from the operating room to the PACU?
They must have a patent airway, adequate ventilation, and oxygenation, and be hemodynamically stable. Qualified anesthesia personnel must attend the transfer.
What should be done if a patient at risk of hypoxemia is transported from the operating room?
Supplemental oxygen should be administered during transport.
How should patients with pulmonary dysfunction or at risk for vomiting be transported?
Patients should be transported in a lateral position to prevent airway obstruction and facilitate drainage of secretions.
What must be assessed immediately upon PACU arrival after general anesthesia?
Airway patency, vital signs, oxygenation, and level of consciousness.
How frequently are vital signs measured in the PACU after general anesthesia?
At least every 5 minutes for 15 minutes or until stable, and every 15 minutes thereafter.
Which monitoring should be continuous for all patients recovering from general anesthesia?
Pulse oximetry.
What should be assessed clinically to monitor neuromuscular function?
Head-lift and grip strength.
What must be included in the anesthesia provider’s report to the PACU nurse?
Preoperative history, intraoperative events, expected postoperative problems, PACU medication administration, and postanesthesia orders.
Why is supplemental oxygen used in patients recovering from general anesthesia?
To prevent transient hypoxemia, which can develop even in healthy patients.
How should oxygen therapy be controlled in patients with chronic obstructive pulmonary disease?
Carefully controlled to avoid CO2 retention.
What is the recommended patient position during recovery from general anesthesia to optimize oxygenation?
Patients should be nursed in the back-up position, whenever possible.
What should be monitored in patients recovering from regional anesthesia?
Sensory and motor levels, blood pressure, and potential bladder catheterization.
How should postoperative pain be controlled for moderate to severe pain?
Oral or parenteral opioids.
What are some opioid-sparing strategies for postoperative pain management?
Preoperative administration of NSAIDs, acetaminophen, gabapentin, and postoperative local anesthetic modalities.
What are the most common medications for mild to moderate postoperative pain?
Acetaminophen, ibuprofen, hydrocodone, or oxycodone.
How should opioids be administered for moderate to severe pain in the PACU?
Parenteral or intraspinal opioids, single-shot or continuous nerve blocks, or continuous epidural analgesia.
What is the effect of epidural fentanyl or sufentanil on postoperative pain?
It provides excellent pain relief.
What should be done to manage postoperative agitation before the patient is fully responsive?
Consider causes like hypoxemia, acidosis, or a surgical complication, and treat with sedation if necessary.
How should postoperative nausea and vomiting (PONV) be prevented?
Use of 5-HT3 antagonists like ondansetron, granisetron, or dolasetron.
Which risk factors are associated with increased PONV?
Young age, female gender, history of postoperative emesis, and surgeries like laparoscopy or breast surgery.
How can hypothermia-induced shivering be treated in the PACU?
Use a forced-air warming device or administer small doses of meperidine.
Which conditions may cause postoperative shivering besides hypothermia?
Bacteremia, sepsis, drug allergy, or transfusion reaction.
What criteria should be met before discharge from the PACU?
Easy arousability, full orientation, stable vital signs, no surgical complications, and controlled pain and nausea.
What additional factors must be considered when discharging patients after regional anesthesia?
Regression of both sensory and motor blockade.
What is the typical discharge process for outpatient surgery?
Patients are fast-tracked to phase 2 recovery and must be accompanied by a responsible adult.
What is the primary assessment for home readiness following outpatient surgery?
Proprioception, sympathetic tone, bladder function, and motor strength recovery.
How long does complete psychomotor recovery usually take for outpatient surgery?
24–72 hours.
What are the most common respiratory complications in the PACU?
Airway obstruction, hypoventilation, and hypoxemia.
What is the most common cause of airway obstruction in unconscious patients?
The tongue falling back against the posterior pharynx.
What maneuvers can be used to alleviate partial airway obstruction?
Jaw-thrust and head-tilt maneuver, and insertion of an oral or nasal airway.
What is the initial management of laryngospasm in the PACU?
Jaw-thrust maneuver with gentle positive airway pressure, and insertion of an oral or nasal airway.
What should be administered for refractory laryngospasm?
Small dose of intravenous succinylcholine (10-20 mg in adults) and positive-pressure ventilation with 100% oxygen.
What medication can be used to treat glottic edema following airway instrumentation in infants and young children?
Intravenous corticosteroids (dexamethasone, 0.5 mg/kg) or aerosolized racemic epinephrine (0.5 mL of 2.25% solution with 3 mL saline).
How should post-operative wound hematomas affecting the airway be managed?
Immediate opening of the wound to relieve tracheal compression.
How should accidental decannulation of a fresh tracheostomy be managed?
Only performed with a qualified surgeon at the bedside, with appropriate airway equipment immediately available.
How is hypoventilation defined in terms of Paco2?
Hypoventilation is generally defined as Paco2 >45 mm Hg.
What are common signs of significant hypoventilation in the PACU?
Excessive somnolence, slow respiratory rate, tachypnea with shallow breathing, or labored breathing.
What is the primary cause of hypoventilation in the PACU?
Residual depressant effects of anesthetics on respiratory drive.
How should opioid-induced respiratory depression be managed?
Titration of naloxone in small increments (80 mcg in adults) to reverse hypoventilation without significantly reversing analgesia.
What is the first-line treatment for significant hypoventilation in the PACU?
Assisted or controlled ventilation until the underlying cause is identified and corrected.
What are some causes of residual muscle paralysis in the PACU?
Inadequate reversal, pharmacological interactions, altered pharmacokinetics, metabolic factors like hypokalemia or respiratory acidosis.
How is residual paralysis diagnosed in unconscious patients?
With a nerve stimulator.
What should be done if residual paralysis is present despite a full dose of a cholinesterase inhibitor?
Controlled ventilation under close observation until spontaneous recovery occurs.
What is the usual cause of hypoxemia in the PACU?
Hypoventilation, increased right-to-left intrapulmonary shunting, or both.
What is the common cause of hypoxemia following general anesthesia?
Decreased functional residual capacity (FRC) relative to closing capacity.
What should be done to treat hypoxemia in the PACU?
Oxygen therapy with or without positive airway pressure, and other measures based on the underlying cause.
What are common causes of hypoxemia due to hypoventilation?
Marked hypercapnia or concomitant intrapulmonary shunting.
What is the management of postoperative hypoxemia due to a pneumothorax?
Chest tube or Heimlich valve insertion for symptomatic pneumothorax.
How should postoperative pulmonary edema be managed?
Diuretics and optimization of cardiac function.
What is the treatment for significant hypotension in the PACU?
Fluid bolus (250–500 mL crystalloid or 100–250 mL colloid), and
vasopressors/inotropes (dopamine or epinephrine) if needed.
What are the signs of cardiac dysfunction in the PACU?
Signs include failure to respond to fluid bolus, and may require invasive hemodynamic monitoring or echocardiographic examination.
What is the immediate management of hypotension due to a tension pneumothorax?
Immediate pleural aspiration, even before radiographic confirmation.
What are common causes of postoperative hypertension in the PACU?
Incisional pain, endotracheal intubation, bladder distention, or the neuroendocrine stress response.
What is the treatment for mild postoperative hypertension in the PACU?
Mild hypertension generally does not require treatment, but a reversible cause should be sought.
What is the treatment for severe postoperative hypertension in the PACU?
Intravenous β-blockers (labetalol, esmolol), ACE inhibitors (enalapril), or calcium channel blockers (nicardipine), or intravenous infusion of nitroprusside or other vasodilators for patients with limited cardiac reserve.
What are common arrhythmias seen in the PACU?
Bradycardia, tachycardia, premature atrial and ventricular beats, and supraventricular tachyarrhythmias.
What is the cause of bradycardia in the PACU?
Residual effects of cholinesterase inhibitors, opioids, or β-adrenergic blockers.
What can cause tachycardia in the PACU?
Anticholinergic agents, β-agonists (like albuterol), reflex tachycardia from hydralazine, pain, fever, hypovolemia, and anemia.
What is the treatment for premature atrial or ventricular beats in the PACU?
Correction of underlying causes such as hypokalemia, hypomagnesemia, or ischemia.
What are the perioperative causes of tachycardia?
Anxiety, Pain, Fever, Hypoxemia, Hypercapnia, Hypotension, Anemia, Hypovolemia, Congestive heart failure, Cardiac tamponade, Tension pneumothorax, Thromboembolism, Antimuscarinic agents, β-Adrenergic agonists, Vasodilators, Allergy, Drug withdrawal, Hypoglycemia, Thyrotoxicosis, Pheochromocytoma, Adrenal (addisonian) crisis, Carcinoid syndrome, Acute porphyria
What are the perioperative causes of fever?
Infections, Immunologically mediated processes, Drug reactions, Blood reactions, Tissue destruction (rejection), Connective tissue disorders, Granulomatous disorders, Tissue damage (Trauma, Infarction, Thrombosis), Neoplastic disorders, Metabolic disorders (Thyroid storm, Adrenal (addisonian) crisis, Pheochromocytoma, Malignant hyperthermia, Neuroleptic malignant syndrome, Acute gout, Acute porphyria)
What should be done if a young adult male with a femur fracture shows persistent tachycardia and fever?
Evaluate the causes of tachycardia and fever (possible thyrotoxicosis, infection, pain, anxiety, hypovolemia, etc.), and assess further with appropriate investigations like chest X-ray, arterial blood gas, and thyroid hormone levels. Delay surgery until a diagnosis is clear.
What is the most likely cause of tachycardia and fever in the young adult male with a femur fracture?
Possible causes include infection (e.g., wound, pulmonary, or urinary), pain, anxiety, hypovolemia, pulmonary fat embolism, or thyrotoxicosis (suggested by enlarged thyroid).
What additional measures should be taken to evaluate tachycardia and fever in the young adult male with a femur fracture?
Arterial blood gas measurement, chest film, repeat hematocrit or hemoglobin, fluid challenge, sedation, thyroid hormone measurement, and cultures if infection is suspected.
What is the likely diagnosis for a patient showing excessive adrenergic activity, fever, increased fluid needs, and delirium after surgery?
Thyroid storm, a hypermetabolic state caused by severe thyrotoxicosis, with a high mortality rate if untreated.
What are the key features of thyroid storm?
Fever, tachycardia, hypotension, delirium or coma, atrial and ventricular arrhythmias, heat intolerance, nausea, vomiting, diarrhea, and hypokalemia. Often precipitated by stressors like surgery.
What is the management for thyroid storm?
Corticosteroids, propylthiouracil, iodine, propranolol, supportive care with cooling blankets, acetaminophen, and fluid replacement. Vasopressors may be needed for hypotension. β-blockers should be used cautiously in congestive heart failure.
What is the significance of β1 and β2 blockade in thyroid storm?
Combined β1- and β2-blockade is preferred because β2-blockade reduces muscle blood flow and metabolic heat production. It also helps in controlling adrenergic symptoms, including tachycardia and hypertension.
What is the role of propranolol in managing thyroid storm?
Propranolol antagonizes the peripheral effects of thyrotoxicosis and inhibits the peripheral conversion of T4 to T3, which is helpful in controlling symptoms.
What is the management approach if a thyroid storm patient is in atrial fibrillation?
Ventricular rate control with β-blockers, and possible echocardiography or hemodynamic monitoring for patients with signs of heart failure or persistent hypotension.
Why is esmolol administered during surgery in patients with tachycardia?
Esmolol is used to decrease tachycardia and manage adrenergic symptoms by providing short-acting β-blockade.
What are the signs that suggest thyroid storm after surgery?
Mental status changes, excessive adrenergic activity, worsening fever, and signs of hypotension or arrhythmias despite fluid resuscitation and medications.
