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Principles > Principles-PACU/Cardioversion/ECT > Flashcards

Principles-PACU/Cardioversion/ECT Flashcards

1
Q

What is the discharge criteria from the PACU to floor

A

Must be evaluated by Anesthesia
Aldrete Score or modified Aldrete of at least 9/10
Vital signs must be stable for at least 30 min before discharge
NO shivering, but normal temp not required
No opioids for at least 30 minutes
No supplemental 02 for 15 minutes, unless nasal cannula

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2
Q

List discharge criteria from PACU to home

A

modified aldrete score-outpatient discharge
Discharged to Responsible adult in 1-2 hrs
No discharge if vomiting present
No discharge for residual sensory anesthesia
Ambulate without dizziness or hypotension

May discharge without p.o. intake
May discharge without voiding

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3
Q

What is the Aldrete scoring system

A

This system is designed to assess the patients transition from phase I recovery to Phase II recovery, from discontinuation of anesthesia until return of protective reflexes and motor function

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4
Q

What does the Aldrete scoring system assess

A 
activity to command
breathing
Systolic BP
LOC
Oxygenation

*1-10 scale; > 9 (ok to discharge)

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5
Q

What are the most common problems in the PACU

A

PAIN, then
N/V
Hypertension requiring tx
Upper airway support needs

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6
Q

Upper airway obstruction is caused by

A

obstruction of pharynx-tongue falling posteriorly

laryngospasm or edema from intubation

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7
Q

What are the signs of U. airway obstruction

A

Flaring of nares
Retraction at the sternal notch/intercostal spaces d/t tracheal tug
Unsynchronized abdominal/diaphragmatic contraction

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8
Q

How do you treat a pharyngeal obstruction

A

Extend head with anterior displacement of mandible (head-tilt-jaw-thrust)
Support respirations
Nasal (awake pts.) or Oral (sedated pts.) airway

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9
Q

How do you treat a laryngospasm

A

Head-tilt-Chin-lift with + pressure & 100% 02
complete laryngospasm- low dose (10-20 mg) IV succinylcholine followed by DL and intubation
Crycothyrotomy in emergency

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10
Q

How do you treat laryngeal edema

A

Racemic epinephrine neb tx with 0.25-0.5 cc of 2.25% epi in 5cc water or NS
Dexamethasone

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11
Q

Prolonged upper airway obstruction can lead to

A

Pulmonary edema

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12
Q

What blood level of Pa02 defines arterial hypoxemia

A

Pa02 less than 60 mmHg

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13
Q

Pa02 decrease by —– mmHg following upper or thoracic surgeries

A

20 mmHg

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14
Q

Pa02 decreases by —–mmHg following lower abdominal surgery

A

10 mmHg

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15
Q

Pa02 decreases by ——following upper extremity surgery

A

6 mmHg

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16
Q

What are the most common causes of hypoxemia

A

Increased r-l shunt secondary to atelacstasis

V/Q mismatch which is worsened by decreased FRC and decreased CO

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17
Q

How is hypoxemia treated

A

Supplemental 02 until problem fixed

*must have sa02> 94% to d/c 02

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18
Q

What causes hypoventilation

A

decreased CNS stimulation for ventilation r/t anesthetics

respiratory depression r/t prolonged muscle relaxant, or inadequte reversal

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19
Q

Treatment for hypoventilation from inhaled agents

A

If pt maintaing airway, allow spontaneous recovery

If pt not maintaining airway, cuffed ETT and mechanical ventilation required

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20
Q

Treatment for hypoventilation from Opioids

A

SMALL doses of Narcan 40 mcg at a time

*rapid administration results in massive SNS discharge leading to pulmonary edema

21
Q

Treatment of hypoventilation from muscle relaxants

A

Monitor TOF
May require mechanical ventilation until return of TOF

*Careful not to exceed reversal dose

22
Q

List the most common causes of hypotension

A

HYPOVOLEMIA
inadequate blood, or fluid replacement, bleeding
Postop M.I.
and others

23
Q

Treatment of hypotension includes

A

Monitoring BP & UO
Trendelenberg position
Pressors and fluid

24
Q

What cardiac dysrhythmia is most common

A

Sinus Tachycardia r/t arterial hypoxemia, hypovolemia, or pain

25
Q

What is delayed emergence

A

When a patient fails to awakening in 30-60 min of expected time

26
Q

What is the differential diagnosis for delayed emergence

A

Start by evaluating VS and neuro exam
ABG, glucose, electrolyte, and pH
Neurologic consult

*Overdose of anesthetics most common cause

27
Q

Treatment of delayed emergence includes

A

Treat cause of sedation
Warm blankets
R/O more severe neuro problems

28
Q

What are common causes of N/V in the postop patient

A 
previous hx of n/v, or motion sickness
female, period less than 7 days prior to surgery, obesity, nonsmoker
postop pain meds with opioids
middle ear, laproscopic, eye surgery
gastric distension
29
Q

Treatment of postop N/V include

A

Ondansetron, droperidol, phenergan, dexamethasone

avoid offending agents

30
Q

What is elective cardioversion indicated for

A

A.Fibrillation (symptomatic)
can termination of A.Fib, A.Flutter, AV nodal reentry, V. tach, and V. fib

  • done with sedation
  • unstable A.fib requires 50-100 J
31
Q

What is emergency cardioversion indicated for

A

Any tacharrhythmia associated with hypotension, CHF, or angina

*done without sedation

32
Q

What equipment is necessary for safe cardioversion

A 
Airway management personnel
VS, LOC monitoring q5 min
Direct current defibrillator (synchronized)
IV access
Bag mask with 100% 02
Airway kit (oral/nasal airway and ETT)
Suction
Stethscope
Crash cart with transcutaneous pacer
33
Q

List the complicatons of cardioversion

A

Transient myocardial depression
Arterial embolism
Post shock arrhythmias

*embolism may be cause of delayed emergence following cardioversion

34
Q

What is ECT

A

is a psychiatric treatment in which seizures are electrically induced in anesthetized patients for therapeutic effect

*Dangerous b/c a complete resetting of SNS/PSNS is initiated

35
Q

Describe the physiology of ECT

A

Causes a seizure with an initial PSNS discharge followed by a sustained SNS discharge

bradycaria followed by asystole (up to 6 seconds)
Then, tachycardia and hypertension for several minutes

36
Q

What are the Side effects of ECT

A

Arrhythmias and t-wave changes associated with transient autonomic imbalance

Cerebral blood flow, ICP, intragastric pressure, IOP increases transiently

37
Q

Contraindications of ECT

A 
Absolute: 
M.I (within 3 months
Stroke (within 1 month)
Increased ICP
Intracranial mass
38
Q

Seizures from ECT cause

A

Confusion
Antegrade Amnesia
Somnolence

39
Q

Premedication should be done with

A

glycopyrrolate-to dec. bradycardia and secretions
Nitroglycerin, nifedipine, a/b blockers

*b blockers decreased seizure duration

40
Q

Efficacy of ECT is r/t

A

duration of induced seizure

  • goal of 30-60 seconds of seizure activity
  • cured after 400-700 seizure second in total
41
Q

Anesthetic drugs do what to the efficacy

A

decrease

42
Q

What is the anesthetic goal with ECT

A

The essential elements of anesthesia for ECT include rapid loss of consciousness,
effective attenuation of the hyperdynamic response to the electrical stimulus,
avoidance of gross movements, minimal interference
with seizure activity,and prompt recovery
of spontaneous ventilation and consciousness.

43
Q

What is the gold standard drug used with ECT

A

Methohexital

*no change in seizure duration

44
Q

What anesthetic drugs and factors increase the seizure duration

A 
Caffeine
Etomidate 
Alfentanil
Remifentanil
Ketamine- dont use

Hyperventilation-vasoconstriction

45
Q

What effect does induction agents have on seizure threshold

A

Raises it

46
Q

What anesthetics decrease seizure duration

A

STP
Nitroglycerine
A/B and calcium channel blockers

47
Q

What is the most commonly used NMBA with ECT

A

Succinylcholine 0.5-1.0 mg/kg

48
Q

True/False

A patient with a pacemaker can received ECT

A

TRUE but a magnet must be available

Principles (8 decks)

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