Test 4: PACU (pt. 1/3) Overview, Airway Flashcards
What are the 3 levels of postanesthesia care?
Phase 1, Phase 2, and Extended Care
What are the goals of Phase 1 Postanesthesia?
Recovery from anesthesia and return of baseline VS.
-PACU scoring criteria, VS assessment, manage respiratory & hemodynamic changes
-Provide analgesia & antiemetics
What are the goals of Phase 2 Postanesthesia care?
Continued recovery based on facility policy/patient need
What is Fast-tracking postop care?
Occurs when the patient bypasses Phase 1 care and moves directly from the OR to Phase 2.
-Monitored Anes Care Surgeries
What is Extended Care?
The patient meets criteria to leave Phase 1 PACU, but is unable to go to another location for some other reason.
-Ex: Lack of available beds.
What should you assess before fast-tracking your patient?
Patient’s postop alertness, physiologic stability, and comfort level
What are the goals of the AANA Standard 11: Transfer of Care?
1) Evaluate the patient’s status and determine when it is appropriate to transfer the responsibility of care → to another qualified healthcare provider
2) Communicate the patient’s condition and essential information for continuity of care
The anesthesia provider cannot shift responsibility to the PACU until the patient’s airway status, ventilation, and hemodynamics are appropriate.
According to AANA Standard 11, how should you communicate the patient’s condition?
-Two-way verbal exchange
-nonhierarchical culture of open communication
-a location free of distraction/interruptions
-adherence to facility policy defines expectations & professional accountability
What is the IMMEDIATE PRIORITY in the PACU Admission?
The immediate priority is evaluation of respiratory and circulatory adequacy.
What do you need to do before and while transporting patient to PACU?
1) Notify PACU staff so they can have necessary equipment available (vent, nebulizer, etc).
2) Inform PACU staff of patient’s acuity for proper assignment
3) The anesthesia provider should be active during the patient’s transfer and stabilization in the PACU.
4) Assistance in the initiation of oxygen therapy, maintenance or verification of airway adequacy, and assessment of circulatory status familiarizes PACU personnel with the patient and fosters a smooth transfer of care.
5) After initially stabilizing the patient, the anesthesia provider can communicate relevant preoperative and intraoperative data to the PACU nurse.
What is the purpose of the anesthesia handoff/transfer of care in the PACU?
To decrease communication errors, increase patient safety & continuity of care, and provide better post op care.
Handoff must be standardized and communicated in a logical manner (checklist).
What are some of the key elements in the anesthesia report?
-Pt demographics/history
-procedure/anesthetic type
-airway
-baseline VS
-neuro status
-pertinent labs
-meds administered
-intraop events
-I&O
-lines
-postop orders
-how to contact us
Describe the INITIAL PACU Assessments.
-determine pt physiologic status at time of admission
-establish pt baseline level
-allow periodic reexamination to follow physiologic trends
-assess status of surgical site
-assess recovery from anesthesia
-prevent/manage complications
-provide a safe environment for recovery
-allow data/trend analysis for discharge or transfer criteria
What is the Aldrete Score?
The most commonly used assessment approach is a combination of a scoring system and a major body systems assessment.
It scores activity, respiratory effort, circulation, level of consciousness, and oxygen saturation which is a direct reflection of respiration.
What is discharge criteria on the Aldrete Score?
9-10
What are the 5 components of the Aldrete Score?
activity
respiratory effort
circulation
level of consciousness
oxygen saturation
Describe the Respiratory PACU Assessment.
Immediate!! Need O2 and pulse ox when you arrive.
Composed of:
-rate & depth of ventilation
-auscultation of breath sounds
-oxygen saturation level
-end-tidal carbon dioxide, if appropriate.
Type of oxygen delivery system and presence of any artificial airway should be noted.
Describe the Cardiovascular PACU Assessment?
The heart is auscultated, and the quality of heart sounds, the presence of any adventitious sounds, and any irregularities in rate or rhythm are noted. Unexpected findings are compared with preoperative data. Arterial pulses are evaluated for strength and equality. An ECG strip is obtained on admission to the PACU and compared with the preoperative ECG.
Describe the Neurologic PACU Assessment?
The neurologic system is evaluated, with a focus on the level of consciousness, orientation, sensory and motor function, and pupil size, equality, and reactivity. The patient is assessed on ability to follow commands and move extremities purposefully and equally.
In addition, body temperature, as well as skin color and condition are assessed and the findings documented.
Describe the Renal PACU Assessment.
The renal system assessment focuses on fluid intake and output (e.g., blood, crystalloids, and colloids), as well as on volume and electrolyte status.
What is the most common cause of airway obstruction in the immediate postoperative phase?
The loss of pharyngeal muscle tone in a sedated or obtunded patient.
What causes the loss of pharyngeal muscle tone immediately after surgery?
The loss of pharyngeal muscle tone immediately after surgery is mainly due to the lasting effects of the anesthetic agents, opioids, and/or residual NMB.
What is the cause of most upper airway obstructions?
The tongue
How does the tongue cause an upper airway obstruction?
Obstruction occurs when the tongue falls back into a position that occludes the pharynx and blocks the flow of air into and out of the lungs.
What are Signs and symptoms of an upper airway obstruction?
-snoring
-accessory muscles of ventilation
-Intercostal and suprasternal retractions
-somnolent, and may be difficult to arouse.
What is the goal for the relief of a tongue obstruction?
A patent airway
What is the initial intervention for relief of an upper airway obstruction (usually tongue)?
1) Stimulating the patient to take deep breaths
2) it may require repositioning of the airway via a jaw thrust or a chin lift
3) Placement of an oral or a nasal airway may be required
4) If the obstruction remains unrelieved, reintubation may be required, with or without adjunctive mechanical ventilation.
How can a laryngeal obstruction occur?
Laryngeal obstruction may occlude the airway as a result of partial or complete spasm of the intrinsic or extrinsic muscles of the larynx.
What are some sources of airway irritation that can predispose a patient to laryngospasm?
-laryngoscopy
-secretions
-vomitus
-blood
-artificial airway placement
-coughing
-bronchospasm
-frequent suctioning
What are symptoms that suggest laryngospasm?
-agitation
-decreased oxygen saturation
-absent breath sounds
-acute respiratory distress
Incomplete obstruction may manifest as a __________ or _____.
crowing sound or stridor
What is the treatment of a laryngospasm?
1) 100% Fio2, suction/removal of stimulus
2) Jaw thrust + CPAP (up to 40 cmH2O)
3) Subparalytic dose of succ (0.15–0.5 mg/kg) or 4 mg/kg intramuscularly [IM])
4) Assisted ventilation after succ administration
5) Reintubate only if severe airway edema is present or if the obstruction persists despite tx
6) Consider sedation (midazolam), corticosteroids, and/or IV Lidocaine
What are other preventive strategies for laryngospasm during surgery?
-obtaining meticulous hemostasis during surgery
-suctioning the oropharynx before extubation to clear any retained blood or secretions
-extubating the patient when they are either in a very deep plane of anesthesia or the awake state
What is Obstructive Sleep Apnea (OSA)?
Diminished muscle tone in the airway which leads to airway obstruction during sleep.
There is a high prevalence of diagnosed and undiagnosed OSA with an estimated ____ to ____ million adults undiagnosed.
There is a high prevalence of diagnosed and undiagnosed OSA with an estimated 12 to 18 million adults undiagnosed.
What is the screening instrument with the highest validity and ease of use for OSA?
STOP-BANG Questionnaire
What is STOP-BANG?
Snoring
Tiredness
Observed Apnea
High Blood Pressure
BMI > 35
Age > 50
Neck Circumference > 40 cm
Gender (male)
What are the perioperative complications associated with OSA?
-Difficult intubation
-Obstruction
-Increased Length of stay in the PACU
-Unplanned admission
-Other respiratory and CV complications
What is the anesthetic plan for OSA?
-RA with minimal sedation
-Multimodal pain mgmt
What is the postop management of OSA?
-analgesia
-positioning
-oxygenation
-monitoring
-CPAP
What is the definition of hypoxemia?
Low arterial oxygen pressure (PaO2), usually less than 60 mmHg.
What are the signs/symptoms of hypoxemia?
Nonspecific:
-Agitation to somnolence
-HTN to HoTN
-Tachycardia to Bradycardia
-can be confirmed via Pulse Ox and ABG
What does untreated hypoxemia lead to?
Hypoxemia, if untreated, can result in organ ischemia.
What are the most common causes of hypoxemia in the PACU?
-Atelectasis
-Pulmonary edema
-Pulmonary embolism (PE)
-Aspiration
-Bronchospasm
-Hypoventilation
What is the MOST COMMON cause of postoperative hypoxemia?
Atelectasis
-Can lead to an increase in right-to-left shunt
What causes atelectasis?
-Bronchial obstruction due to secretions
-Decreased lung volumes
Hypotension and low CO can also contribute to the development of decreased perfusion and atelectasis.
What are the treatment options for atelectasis?
-Supplemental humidified oxygen
-Turn, coughing, deep breathing, postural drainage, and increased mobility
-Incentive spirometry
-Intermittent positive-pressure ventilation
What causes pulmonary edema?
Fluid accumulation within the alveoli.
May be the result of:
-an increase in hydrostatic pressure (fluid overload, LV failure, IHD)
-a decrease in interstitial pressure (seen after prolonged airway obstruction such as laryngospasm), or
-an increase in capillary permeability (sepsis, aspiration, transfusion rxn, trauma, DIC, ARDS)
Acute pulmonary edema that occurs shortly after relief of severe upper airway obstruction is called ?
Postobstruction or negative-pressure pulmonary edema or noncardiogenic pulmonary edema.
What causes negative-pressure pulmonary edema?
Develops acutely after severe upper airway obstruction
-Ex: Biting on ETT during emergence (usually in young, healthy males). Very important to have a bite block in place.
Also can be due to:
-Incomplete reversal of NMB
-Bolus dosing with naloxone
-Significant period of hypoxia
What are the S/Sx of Pulmonary Edema?
-hypoxemia
-cough
-frothy sputum
-rales on auscultation
-decreased lung compliance
-pulmonary infiltrates seen on chest radiography
What is the treatment for Pulmonary edema?
Overall: Identify cause and reduce hydrostatic pressure in the lungs.
-Maintain oxygenation via mask or CPAP, or intubation if necessary with mechanical ventilation & PEEP
-Diuretics and fluid restriction
T/F: Patients with noncardiogenic Pulmonary edema usually recover very slowly, with serious permanent complications.
False; Patients with noncardiogenic pulmonary edema usually recover quickly after the acute phase and have no permanent sequelae.
Where are the three conditions that place patients at increased risk for Pulmonary Embolism (PE)?
Virchow’s Triad:
Venous Stasis
Hypercoagulability
Vascular Trauma
What conditions accentuate the risk of PE?
-Obesity
-Varicose veins
-Immobility
-Malignancy
-CHF
-Inc age
-Pelvic or long bone fx or surgery
90% of all pulmonary emboli arise from _______________________.
90% of all pulmonary emboli arise from deep veins in the legs.
What causes thrombosis in specifically postop patients?
Thrombosis in postoperative patients seems to be related to surgical tissue trauma and liberation of tissue factor that leads to thrombin formation.
What are the S/Sx of a PE?
-Acute onset Dyspnea/tachypnea
-Chest pain
-Tachycardia
-Hypotension (shock)
-Hemoptysis
-Dysrhythmias
-CHF
What are the S/Sx of a DVT?
-Painful swelling of extremity
-Fever
What are the preventive measures employed to reduce the risk of PE?
-Antiembolic stockings
-Sequential Compression devices
-Subcut heparin therapy
What is the treatment for a PE?
-Correction of hypoxemia and hemodynamic support
-IV Heparin therapy (aPTT 1.5-2x control)
What is aspiration?
A potentially serious airway emergency that can compromise patient safety and stability on the induction of, or the emergence from, anesthesia.
-Can occur in the OR, in the PACU, or during transfer
-Can aspirate foreign matter (tooth), food, blood, or GI contents
What is the most severe form of aspiration?
Aspiration of gastric contents, as it may result in a chemical pneumonitis.
What are the S/Sx of aspiration of gastric contents (Chemical pneumonitis)?
-diffuse bronchospasm (secondary to reflex airway closure)
-hypoxemia (compromised alveolar-capillary membrane)
-atelectasis (loss of surfactant)
-interstitial edema (loss of capillary integrity)
-hemorrhage
-infection
-adult respiratory distress syndrome
Which patients are most at risk for aspiration?
-Obese
-Pregnancy
-GERD/Hiatal Hernia
-PUD
-Trauma
What is the tx of gastric aspiration?
Correct any hypoxemia and hemodynamic instability.
-Supplemental O2, PEEP, CPAP, or Mechanical ventilation
-Abx only if signs of infection occur (fever, leukocytosis, or + culture)
Should you administer corticosteroids after gastric aspiration?
No beneficial effect of corticosteroids has been determined. Administration of corticosteroids produce no positive effects, but may contribute to bacterial superinfections.
What drugs reduce both gastric volume and acidity and can reduce risk of aspiration?
-H2 antagonists and PPIs both reduce gastric volume and acidity.
-H2s must be given a few hours before surgery
-PPIs have best results when given in 2 successive doses.
Antacids only increase gastric pH. No effect on gastric volume.
What type of antacids should be used for aspiration prophylaxis?
ONLY Nonparticulate antacids (Sodium citrate)
T/F: Anticholinergics like Atropine are proven to help in reducing the risk of aspiration.
False; Use of anticholinergic medications to decrease the risk of aspiration is not recommended as atropine and glycopyrrolate have not been shown to effectively reduce gastric volume or acidity - may actually do opposite
Which drug is a gastric prokinetic that can reduce gastric volume?
Metoclopramide (Reglan)
What is the purpose of doing a Rapid Sequence Induction with Cricoid Pressure?
-May serve to hasten protection of the airway with a cuffed endotracheal tube (ETT) and limit opportunity for aspiration of gastric contents.
-Cricoid pressure or Sellick’s maneuver (20 newtons) may alter laryngeal view, must weigh the pros/cons
What are the “cons” associated with Cricoid Pressure?
-Alter laryngeal view
-VC Closure
-Difficult ventilation
-Esophageal rupture with active vomiting
Have to rule out tracheal and/or C-Spine injury, C/I with active vomiting
What do you need to know regarding LMA and aspiration?
Usage of a laryngeal mask airway (LMA) remains controversial in patients with active reflux disease. The absence of definitive airway protection with LMA must be carefully considered, and a reasonable indication against endotracheal intubation should be present prior to implementation.
What causes a bronchospasm?
Bronchospasm results from an increase in bronchial smooth muscle tone, with resultant closure of small airways.
-Aspiration
-Pharyngeal or tracheal suctioning
-Endotracheal intubation
-Histamine release secondary to medications, or an allergic response
-Inc frequency in pts with hx of asthma or COPD
-Light anesthesia (deepen anesthetic)
What are the S/Sx of Bronchospasm?
-wheezing
-dyspnea
-use of accessory muscles
-tachypnea
-increased airway resistance
-increased peak inspiratory pressures on vent if under anesthesia
What is the Tx for Bronchospasm?
-Beta 2 agonists (albuterol) or long acting (Salmeterol)
-IV Epi if life-threatening
-Anticholinergics (Atropine, glyco) via nebulizer to dec secretions
-Steroids (if cause is inflammation like w/asthma)
-IV/Inhaled Lidocaine (for histamine induced)
-Inhalation anesthetics (Sevo)
What is the definition of hypoventilation?
-a decrease in respiratory rate that results in an increase in Pa co 2 secondary to a decrease in alveolar ventilation.
-may occur because of a decrease in central respiratory drive, poor respiratory muscle function, or a combination of both.
What causes a depression of central respiratory drive?
IV and Inhalation anesthesia
How does poor respiratory muscle function occur in patients in the peri-op environment?
-inadequate reversal of neuromuscular blocking agents (not as much of a problem with Sugammadex)
-surgery involving the upper abdomen (painful incisions, may affect diaphragm)
-positioning
-obesity
-OSA
-diseases involving the neuromuscular system
Why would a patient be admitted awake/breathing to the PACU and then once they’re extubated, stop breathing?
Once they’re extubated and stimulation is removed, patient stops breathing. Patients also may demonstrate a secondary stage of respiratory depression once certain stimuli are removed.
What are strategies to increase ventilatory function and decrease CO2 in PACU?
-Verbal/tactile stimulation
-TCDB, positioning
-CPAP if OSA
-Monitor SpO2 and capnography
What diseases of the neuromuscular system can effect ventilation? and how should you treat them differently in PACU?
-Muscular dystrophy
-myasthenia gravis
-Eaton-Lambert syndrome
-Guillain-Barré syndrome
-Severe scoliosis
It is often in the best interests of patients with these disorders that they remain intubated in the PACU until complete return of function occurs, and any residual anesthetic effects are absent.
