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
Why can upper abdominal surgeries lead to hypoventilation?
Because of poor diaphragmatic function causing reduced vital capacity.
Obese patient further complicate this as they experience this and increased intra abdominal pressure.
What are some disease of the neuromuscular system that can affect ventilation in a patient post operatively?
Muscular dystrophy, myasthenia gravis, Eaton-Lambert snydrome, Guillian-Barre syndrome and severe scoliosis.
* Keep these patients intubated in the PACU until complete return of function occurs and any residual effects are absent.
Definition of hypotension
Fall of arterial blood pressure more than 20% of baseline or SBP less than 90 mm Hg or MAP below 60 mm Hg
Hypoperfusion leads to __________
Hypoxia –> This leads to lactic acidosis due to anaerobic metabolism taking over
What is hypotension in the PACU most commonly due to?
Hypovolemia –> This is due to inadequate fluid replacement during surgery, blood loss during surgery, or active blood loss.
What is the initial treatment of hypotension in the PACU?
Restore volume –> give a 300-500 cc bolus of NS or LR, if no response to this we can conclude the issue is due to myocardial dysfunction.
What is cardiogenic hypotension?
Due to MI, tamponade, or embolism. Can also be due to the negative inotropy/chronotropy effects of medications.
What drugs cause secondary hypotension due to histamine release?
Atracurium and Morphine
What drugs directly cause hypotension due to vasodilation?
Volatile inhalation, intravenous anesthetics, local anesthetics for spinal anesthesia…
How do tachydysrhythmias cause hypotension?
Prevents adequate ventricular filling and emptying
How should hypotension initially be treated?
Supplemental O2 and elevating the patients legs should occur while the cause is being investigated
What does hypotension due to myocardial dysfunction warrant?
May need coronary vasodilators, inotropic therapy, or afterload reduction (nitroglycerin, dobutamine, or both)
What medications can be used for hypotension due to a low SVR and symptomatic hypo perfusion?
Ephedrine –> 5-50 mg
Epinephrine –> 10-100 mcg
Phenylephrine –> 50-200 mcg
Vasopressin –> 1-4 units
May need a continuous infusion of dopamine or epinephrine.
What are some medications that cause hypotension?
Definition of hypertension
20% higher blood pressure above baseline
What can cause hypertension in the PACU?
PAIN is leading cause!
Also due to –> Stimulation of the SNS, respiratory compromise, visceral distention and significant increases in plasma catecholamine levels
How can pain medications reduce blood pressure?
They reduce the heightened effects of the SNS the patient is experiencing by blocking pain receptors, thereby normalizing blood pressure.
Hypoxemia and hypercarbia cause what effect on blood pressure?
Increase blood pressure initially, later decrease if profound.
What effect does hypothermia have on blood pressure?
Increase due to blood vessels becoming more sensitive to catecholamines as cooling occurs.
Rewarming a patient reverses this process causing vasodilation.
_____ of patients in the PACU have pre-existing HTN
30%
Which antihypertensive medications should be continued preoperatively?
All but ACE inhibitors and ARBS –> This is not a hard cancel if a patient does take prior to surgery
What pharmacologic agents are drugs of choice after a vascular procedure to protect graft sites and prevention of hemorrhage?
Sodium nitroprusside and nitroglycerin
What drugs can be used to treat hypertension in the PACU?
Hydralazine (2-4mg) and Labetalol (5-10mg)
* Labetalol is a beta blocker and alpha 2 agonist leading to decreased HR and vasodilation
What are some causes of dysrhythmias in the PACU?
Most often transient and has an identifiable cause that is not actual myocardial injury –> Hypokalemia, fluid overload, anemia, hypoxia and hypercarbia, altered acid base, substance withdrawal and circulatory instability.
What can excessive gastric suctioning lead to?
Hypokalemia
What should occur if a patient in the PACU complains of chest pain?
Troponin level and 12 lead EKG
* Myocardial ischemia is rarely accompanied by chest pain in post anesthesia patients
How can hypothermia cause dysrhythmias?
Prolongs the refractory period –> This can cause the development of sinus bradycardia and atrial fibrillation
What can direct pressure on the eye or carotid sinus cause?
Vagal nerve stimulation –> This can lead to hypotension and dysrhythmias (Vagal reflexes are usually transient however)
*Neostigmine can also produce vagal reflexes
What are some vagotonic drugs? Vagolytic?
Vagotonic –> Neostigmine (vagal response)
Vagolytic –> Atropine and Glycopyrrolate (inhibits vagal response causing tachyarrhythmias and hypertension)
Ketamine may contribute to _____________ _____________.
Sympathetic stimulation –> tachyarrhythmias and hypertension
_____________ and ___________ concentrations are consistently elevated in PACU patients.
Norepinephrine and Epinephrine –> These increase due to acute pain
What patient population sees residual neuromuscular blockade in the PACU?
Elderly population
What objective monitoring can be implemented to check residual effects from NMB?
Train of four –> Should be preformed regularly in the post anesthesia phase
Why is marginal reversal of NMBA more dangerous than near total paralysis?
Because these patients can be overlooked because they “look” like they are moving or breathing normally.
What is neostigmine or edrophonium chloride given in conjunction with?
Atropine or glycopyrrolate –> to prevent the muscarinic effects of neostigmine/edrophonium such as bradycardia
When can you see prolonged or exaggerated responses to muscle relaxants?
Neuromuscular abnormalities –> Myasthenia gravis, Eaton-Lambert syndrome, or muscular dystrophies.
* Can be seen even WITHOUT muscle relaxant administration
What bedside test can be done to see if the patients strength of ventilatory muscles are adequate?
A forced vital capacity of 10-12 mL/kg and inspiratory pressure of more than -25 cm H2O indicate adequate strength for ventilation.
What is the definition of delirium?
Extreme disturbances of arousal, attention, orientation, perception, intellectual function, and affect –> Most commonly accompanied by fear and agitation.
What population is emergence delirium most prevalent in?
Healthy pediatric, younger adults, combat veterans and patients with preexisting psychiatric disorders/substance abuse patients.
Patient education can help decrease this!
What drugs have been linked to emergence delirium?
Sevo –> Children
Benzo’s –> Adults
What screening tools have been implemented to assess patients from delirium?
Pediatrics –>
Pediatric Anesthesia Emergence Delirium (PAED) scale
Adults –>
Confusion Assessment Method in the Intensive Care Unit (CAM-ICU)
Richmond Agitation Sedation Scale (RASS)
What drug has been shown to be effective in reducing delirium?
Dexmedetomidine preoperatively and intraoperatively.
Low dose ketamine during induction can help as well.
Using the __________ voice verses a strangers has been noted to help reduce pediatric emergence delirium.
mothers
What is delayed awakening?
“Patient should be awake by now but isn’t” –> This is rarely serious and most often due to
1. Prolonged action of anesthetic drugs (MOST COMMON)
2. Metabolic causes
3. Neurologic injury
How does hypoventilation contribute to delayed awakening?
It limits exhalation and prolongs elimination of inhalation agents
Retention of carbon dioxide contributes to narcosis
What herbal supplements can contribute to delayed awakening?
Kava kava, St. John’s wort, and valerian
Which benzodiazepines may contribute to delayed awakening?
Diazepam and lorazepam –> Especially in the elderly
At what blood glucose level would you suspect central nervous system changes?
BG less than 50 mg/dL
What three electrolyte abnormalities can contribute to delayed awakening?
Hyponatremia, hypocalcemia, and hypermagnesemia
What drug can reverse the effects of lorazapam?
Flumazenil –> 0.1-0.2 mg every 1 min for up to 1 mg
What drug can be given to reverse the effects of opioids?
Naloxone (Narcan) –> 40 mcg every 2 mins for up to 200 mcg
What needs to be done in the event of a neurologic cause of delayed awakening?
A CT scan and a neurologic consult
What is serotonin syndrome?
Patients at risk for this are those with chronic pain –> Receiving 2 or more serotonergic drugs (MAOI, TCAs, SSRIs, and fentanyl administration)
Serotonin syndrome triad consists of __________
Autonomic hyperactivity, neuromuscular abnormalities, and changes in mental status.
Patient may present with dilated pupils, diaphoresis, myoclonus, tachycardia, anxiety, and restlessness –>
Can be difficult to diagnose because it mirrors other post anesthesia conditions such as MH and delayed awakening
Because serotonin syndrome may be difficult to diagnose, what should be done?
Knowledge of patients medication history –> Future expansion of CYP2D6 genetic testing can better support identifying patients at risk for this
Treatment of serotonin syndrome?
Cardiac monitoring, supplemental O2, IV fluids, discontinuation of serotonergic drugs and stabilization of vital signs –> This usually resolves within one day
How can benzodiazepines be useful in treating patients experiencing serotonin syndrome?
To control tremors and support physical safety.
What is the most important indicator of patient pain?
The patient’s self report
What is a major source of dissatisfaction in surgical patients?
Pain post operatively –> This impedes mobility and recovery
What patients are at increased risk for post operative pain?
Patients with the CYP2D6 poor metabolizer (PM) genotype and smokers.
What drugs can be administered with opioids to decrease the dosage of opioids and risk for respiratory depression?
NSAIDS and Acetaminophen
What two drugs when given during general anesthesia has been shown to decrease the demand for post operative analgesics?
Magnesium or Dex
What type of analgesia has been effective in weaning patients with obesity or COPD from mechanical ventilation?
Epidural opioid analgesia
What effect does long acting regional analgesic blocks have on the body?
Reduces pain, controls SNS activity, and often improves ventilation.
Besides respiratory depression, what is the most common side effect from opioid use?
Opioid induced bowel dysfunction
What drugs can be given for patients with opioid induced bowel dysfunction?
Alvimopan (Entereg), Naloxegol (Movantik), and Methylnaltrxone (Relistor) –> These can normalize bowel function without blocking systemic opioid analgesia.
What are some non-pharmacologic interventions to help opioid induced constipation?
Positioning for comfort, verbal reassurance, touch, hot/cold therapy, massage, transcutaneous electrical nerve stimulation, imagery, controlled breathing and the use of the patients support system –> This should ONLY supplement and not replace pharmacologic intervention.
What is PROSPECT?
Website which offers current procedure specific guidelines for managing pain associated with various surgical procedures.
True or False
Males experience PONV more than females.
False –> Females experience PONV 2-3x more often than males
Incidence of vomiting is lower than nausea
True or False
Smoking places a patient are increased risk for PONV.
False –> Non smokers and patients with a history of motion sickness are at increased risks for PONV
Smoking is believed to be protective against PONV due to functional changes in neuroreceptors from chronic exposure to nicotine
What is the strongest predictor on PONV?
Use of volatile anesthetics is the strongest predictor –> Decreases with the use of TIVA or regional anesthesia free of opioids, multimodal approaches, and a2 agonist/beta blockers
What are some surgeries that have been associated with higher incidence of PONV?
Cholecystectomy, laparoscopic, and gynecologic surgeries –> These are longer procedures which means longer exposure to inhalation agents.
What are some risk factors associated with an increased risk of PONV?
What two screening tools help assess a patients risk of experiencing PONV?
Koivuranta score and Apfel score
What are some risk factors in children that place them at increased risk for PONV?
Age older than 3, history of PONV or motion sickness, family history of PONV, and females who are post puberty.
Eberhart developed a scale to predict pediatric risk for PONV
How should N/V be managed?
From a prophylactic approach rather than a therapeutic approach –> This includes using multimodal anesthesia with less opioids, avoidance of inhalation agents, use TIVA (prop), and adequate hydration in day surgery patients.
Which NMB reversal agent is better at decreasing the risk of PONV?
Succinylcholine (use this over neostigmine)
Also avoid the use of N2O in surgeries longer than an hour to prevent PONV
According to an Apfel score of 3 on the PONV scale, what does this mean? What about the PDNV scale?
Patient will have a 60% chance of PONV
Patient will have a 50% chance of PDNV
Risk factors for PONV?
Risk mitigation for PONV?
What is best if a patient present with many risk factors for PONV?
Give multiple smaller doses of antiemetics with differing MOAs
What are some drugs that block 5-HT3 receptors? What are they used for
Serotonin receptor blockers –> Ondansetron, granisetron, and palonosetron. Should be administered at the end of surgery to help prevent PONV
These drugs are antiemetics
How does Droperidol work? What is it used for?
Droperidol blocks the dopamine (D2) receptor –> used as an antiemetic at doses of 0.625 mg.
Blackbox warning –> QT prolongation and requires EKG monitoring
What drug can be used if no other dopamine antagonist drug is available for N/V?
Metoclopramide –> a dose of 25-50 mg is better than a lower dose of 10 mg for treating N/V, but there is extrapyramidal side effects with higher doses.
What drug is more effective in reducing postoperative vomiting over postoperative nausea?
NK-1 receptor antagonist –> Only one approved for PONV use is Aprepitant, which blocks substance P from attaching to the NK-1 receptor
Which drug should be administered deep IM opposed to IV for PONV?
Promethazine –> Can cause damage to surrounding tissue if it extravasates
What corticosteroid is as effective as Ondansetron at treating PONV?
Dexamethasone
Which anticholinergic drug can be used to prevent PONV in the PACU and 24 hours postoperativley?
Scopolamine –> placed behind the ear the night before surgery or 2-4 hours before. Contraindicated in older adults and patients with narrow angle glaucoma.
What non pharmacotherapy, 2 things done together, has been shown effective in the treatment of PONV?
Controlled breathing with aromatherapy of isopropyl alcohol swabs
True or False
Crystalloids reduced PONV more effectively in surgeries lasting longer than 3 hours but not in surgeries less than 3 hours.
False –> Colloids
Supplemental crystalloids can reduce early and late PONV at doses of 10-30 mL/kg
What are some common side effects from antiemetic medications?
Agitation, restlessness, and drowsiness
Is using a single or multimodal approach better when treating/preventing PONV?
Multimodal
What does goal directed fluid therapy (GDFT) help prevent?
Postoperative fluid overload
What does early initiation of ingestion of oral fluids in the PACU promote?
Promotes early recovery and prevention of an ileus. Should only be implemented when it is safe for the patient to drink fluids.
What can your body do to compensate for 15-20% of a loss in blood volume without any physiologic indicators of hypovolemia?
Venoconstriction can compensate for like up to 15-20% of fluid loss. After that, other things will need to kick in to compensate (increased HR).
What should be suspected if the patient is experiencing hypotension while rewarming?
Could be hypovolemic –> During hypothermia the body vasoconstricts, allowing a lower intravascular volume to maintain cardiac output.
Why should the ability to void be assessed after using spinal, epidural, regional or opioid anesthesia?
These drugs interfere with sphincter relaxation and promote urine retention.
What is POUR and what populations are at greater risk for it?
Postoperative urine retention –> Diabetes can decrease sensation and contractility in the bladder, and increase bladder capacity. They frequently develop POUR.
Can you discharge a patient home or to the floor without voiding?
Yes, but you need to ensure they are monitoring urine output (need to void 6-8 hours after discharge). If retention persists, the patient should be instructed to contact or go to a hospital to be catheterized.
What is a strong predictor of POUR?
Patient with greater than 400-500 mL of urine in the bladder immediately after spinal anesthesia –> Use a bladder scanner
True or False
Urine color is a good indicator of renal tubular function?
False –> Only good for determining hematuria, hemoglobinuria, or pyuria.
Aldrete scoring systems for discharge?
Aldrete street fitness and Aldrete modified postanesthesia recovery (phase I)
According to Chung post anesthesia discharge scoring system, what score is needed to be discharged home?
At least 9
Who should evaluate a patient prior to discharge from the PACU?
Ideally an anesthesia provider
