Week 15 - PACU Flashcards
What immediate assessment should be preformed when a patient enters the PACU?
Respiratory and circulatory adequacy.
What should be communicated to the PACU staff prior to a patients arrival?
Time expected, necessary equipment, and patient’s acuity
What should occur after the patient has been stabilized in the PACU?
Anesthesia provider gives handoff to PACU nurse –> Give the PACU nurse the opportunity to ask questions.
How can we decrease communication errors during handoff to the PACU nurse?
Use a standardized checklist
AANA Post anesthesia care practice considerations
- Evaluate the patients status and determine when it is appropriate to transfer the responsibility of care to another qualified healthcare provider. Communicate the patient’s condition and essential information for continuity of care
- Hand-off should be a two way interaction, preferably face to face
What does the ASA say should occur before the Anesthesia provider leaves the PACU?
The PACU nurse needs to accept responsibility of the patient.
What are some signs and symptoms of hypoxia?
O2 saturation less than 90%, tachypnea, anxiety…
What are some causes of hypoxemia?
Hypoventilation, diffusion limitation, shunt, V/Q mismatch
What (8) things should the assessment approach include during the PACU assessment?
- Determine patient physiologic status
- Periodic re-examination
- Establish patient baseline data
- Assess surgical site ongoing status
- Assess recovery from anesthesia and residual effects
- Prevent and treat complications immediately
- Provide a safe environment for physically, emotionally, and emotionally impaired patients.
- Compile and trend patient data to relate to discharge
What is the most widely used post anesthetic scoring system?
Aldrete post anesthetic scoring system –> Predictive value has not been studied prospectively in determining recovery from anesthesia.
What should the initial cardiorespiratory assessment consist of when the patient immediately reaches the PACU?
Respiratory –> Rate, depth of ventilation, auscultation of breath sounds, O2 saturation, and EtCO2
Cardiac –> Auscultated for quality of heart sounds, presence of adventitious sounds, and any irregularities in rate or rhythm are noted. Arterial pulses are noted as well as obtaining an EKG and comparing it to the preoperative strip
What should occur after cardiac and respiratory assessments?
Neuro –> Determine LOC, orientation, sensory and motor function, pupil size (equality and reactivity), and the patients ability to follow commands.
What should the renal assessment include?
Fluid intake and output, as well as volume and electrolyte status.
Anesthesia provider should report intra operative fluid totals to the PACU nurse.
What things should be assessed when looking at the surgical site?
Color and amount of drainage on the bandage.
What should be part of the initial/on going assessment of patient status in the PACU?
What is the leading cause of upper airway obstruction of the PACU patient?
Tongue –> falls back and occludes the pharynx
Signs and symptoms –> Snoring and activation of accessory muscles (intercostal and suprasternal) retractions may be noted.
What are some risk factors that place a PACU patient at increased risk of an upper airway obstruction?
- Anatomy (obesity, large or short neck)
- Poor muscle tone (secondary to opioids, sedation, residual NMB, or neuromuscular disease)
- Swelling
Treatment of tongue obstruction in a PACU patient?
- Stimulating the patient to take deep breaths
- Jaw thrust or chin lift w/ continuous positive pressure (10 - 15 cm H2O)
- Placement of an oral/nasal airway
If all these fail, re intubation may be required
Which airway placement device is tolerated better in patients who present with an upper airway obstruction in the PACU? (tongue obstruction)
Nasal –> unlikely to cause gagging or vomiting
What predisposes a patient to laryngospasm?
laryngoscopy, secretions, vomitus, blood, artificial airway placement, coughing, bronchospasm, or frequent suctioning
Symptoms that suggest laryngospasm?
Agitation, decreased O2 saturation, absent breath sounds, and acute respiratory distress.
How may incomplete laryngospasm obstruction present?
Crowing sound or stridor
Treatment of laryngospasm?
Must be immediate! –>
First try jaw thrust with CPAP up to 40 cm H2O, this is generally enough to disrupt the spasm. If this doesn’t work –> Succinylcholine (0.1-1 mg/kg) IV
What needs to occur if Succinylcholine is used to break a laryngospasm?
Assisted ventilation for 5-10 minutes is required, regardless if the obstruction has been relieved.
Also should plan to use sedation prior to administering succinylcholine such as midazolam –> This alleviates the concern of paralyzing an awake or partially awake patient
What are some methods to prevent laryngospasm in the post-operative period?
Use of steroids or topical/intravenous lidocaine, obtaining hemostasis during surgery, suctioning the oropharynx prior to extubation, and extubation in deep anesthesia or completely awake.
What is OSA generally associated with?
Diminished muscle tone in the airway
What standardized screening tool is used to determine OSA risk?
STOP-Bang
What score indicates high risk for OSA when using the STOP-Bang scale?
5-8
What score indicates intermediate risk for OSA when using the STOP-Bang scale?
3-4
What accommodations should be made for a patient with a known diagnosis of OSA prior to surgery?
Have the patient bring their CPAP with them on the day of surgery to be used in the PACU
What is defined as hypoxia?
PaO2 less than 60 mm Hg or a SpO2 less than 90%
What are the most common causes of hypoxemia in the PACU?
- Atelectasis (caused by bronchial obstruction due to secretions or low lung volumes)
Also –> pulmonary edema, pulmonary embolism, aspiration, bronchospasm, and hypoventilation.
Treatment for atelectasis?
Humidified O2, coughing, deep breathing, postural drainage, and increased mobility.
Smoking cessation ______ - ______ weeks prior to surgery decreases atelectasis risk
6-8
What are some preventative strategies of atelectasis?
Adequate pain control and cautious use of NG tubes
What causes pulmonary edema?
Fluid accumulation in the alveoli from –> an increase in hydrostatic pressure (fluid overload), decrease in interstitial pressure (prolonged airway obstruction), or an increase in capillary permeability.
What patients are at increased risk for pulmonary edema during the post obstructions period from issues such as a laryngospasm?
Muscular patients –> They can cause significant negative pressure from forceful inhalation after an obstruction (laryngospasm). This causes a rapid movement of fluid into the alveoli, flooding them.
What are some causes of noncardiogenic pulmonary edema?
Bolus dosing with naloxone, incomplete NMB reversal, and a significant period of hypoxia
Presenting symptoms of pulmonary edema?
Hypoxemia, cough, frothy sputum, rales, decreased lung compliance, and pulmonary infiltrates on CXR
Treatment of pulmonary edema?
Identify the cause and decrease hydrostatic pressure within the lungs! May need –>
1. CPAP via mask or intubation with mechanical ventilation
2. Diuretics and restriction of fluids (Dialysis in patients with renal failure)
3. Preload/afterload reduction via nitroglycerin or sodium nitroprusside –> Used to decrease myocardial work
What is the prognosis of pulmonary edema?
Patients usually recover quickly, within 12-48 hours if treated immediately.
Most cases of PE ________ fatal
AREN’T
What is the triad that places a patient at an increased risk for a PE?
Virchows Triad –> Venous stasis, hypercoagulability, and abnormalities of the blood vessel wall
These are accentuated by –> Obesity, varicose veins, immobility, malignancy, congestive heart failure, increased age, and after a pelvic or long bone injury.
Where do most PE’s arise from?
90% arise from deep veins in the legs –> Use anti embolic stockings or SCDs
What would you suspect in a patient presenting with pleuritic chest pain and dyspnea at rest?
Also can present with –> acute onset tachypnea, dyspnea, chest pain, hypotension, hemoptysis
PE
How to diagnose a PE?
Multidetector CT pulmonary angiography, can provide rapid results –> Has replaced ventilation-perfusion lung scanning
Treatment for PE?
Correction of hypoxemia and hemodynamic stability –> Heparin is started to prevent further clot formation (PTT is 1.5-2 times control), drug of choice in renal disease
Which drugs used to prevent PE’s don’t require coagulation monitoring?
LMWH or fondaparinux or oral rivaroxaban
What does a score of 7 indicate on Well’s clinical prediction rule?
High risk of PE
How is foreign matter aspiration usually removed in the absence of complete upper airway obstruction?
Expelled via patient or bronchoscopy
How is minor aspiration of blood usually cleared?
Cough, resorption, and phagocytosis
What is the likely cause of a patient presenting with pulmonary hemochromatosis (iron accumulation in phagocytic cells)?
Massive blood aspiration –> Leads to fibrinous changes
Aspiration of blood may lead to ______________.
Infection –> especially if the particles of soft tissue are aspirated with the blood.
Treatment of blood aspiration?
Correction of hypoxia, maintenance of airway patency, and initiation of antibiotic therapy if indicated.
What is the most severe form of aspiration?
Aspiration of gastric contents –> may result in chemical pneumonitis
May also lead to laryngospasm, infection, and pulmonary edema
What patient population is at increased risk for gastric aspiration?
The obese, pregnant, or patients with a history of hiatal hernia, peptic ulcers, or trauma –> GI medications are usually given and RSI is utilized in high risk patients.
What can be done intra operatively and post operatively for patients at high risk for gastric aspiration?
Intra operatively –> Place NG tube to decompress the stomach
Post operatively –> Leave the patient intubated until airway reflexes return
Treatment of gastric aspiration?
Correction of hypoxemia and maintenance of hemodynamic stability
* Supplemental O2 with PEEP or CPAP via mechanical ventilation is often necessary
* Antibiotics ONLY at signs of infection
* Corticosteroids produce NO positive effects, not needed
What is a bronchospasm?
An increase in bronchial smooth muscle tone, with the resultant closure of small airways –> Airway edema develops causing secretions to build up in the airway.
What patient population is bronchospasm seen more frequently in?
Patients with a history of asthma or COPD
–> May also be due to aspiration, pharyngeal or tracheal suctioning, ET intubation, histamine release or an allergic response.
Treatment of bronchospasm?
Use of a B2 agonist such as albuterol and intravenous epinephrine.
* Anticholinergics can be used to decrease secretions
* Steroids can be used if the underlying cause is inflammation
What has sevoflurane been reported for use as a rescue therapy?
Severe refractory bronchospasm
What agents can cause depression of central respiratory drive?
Intravenous and inhalation anesthetics –> Central respiratory depression is most profound on admission to the PACU
What is stage 2 of respiratory depression, often seen in the PACU?
Can occur after extubation because of the loss of stimulation from the endotracheal tube, can cause the patient to forget to breath.
True or False
Pulse oximeters monitors the adequacy of ventilation.
False –> Only monitors oxygenation, you will need EtCO2 to monitor ventilation
What can inadequate reversal of NMBA cause?
Hypoventilation due to respiratory muscle weakness.
What medications can potentiate NMBA, causing the patient to experience residual effects even after reversal?
- Aminoglycoside antibiotics –> (gentamicin, clindamycin, neomycin)
- Magnesium (hypermagnesemia)
- Lithium
True or False
Hypokalemia, hypothermia, hypermagnesemia, and acidosis can lead to problems in neuromuscular blockade and reversal?
True