Anesthesia Principles and Practice I: Lecture 3 - PACU/CriticalCare

Question 1

What has changed in the ICU patient population?

Answer 1

Aging Population and advances in minimally invasive surgery and post-op analgesia

Question 2

What is a common complication in surgical critical care?

Answer 2

Post-op wound infection

Question 3

What is major sepsis requiring repeat irrigation and debridement (I&D)?

Answer 3

A surgical complication needing extensive intervention

Question 4

What patients are typically found in a Cardiac ICU?

Answer 4

Patients post major cardiac or pulmonary procedure

Question 5

What is a key focus of the Trauma ICU?

Answer 5

Care for patients post blunt or penetrating trauma

Question 6

What is the focus of Pediatric and Neonatal ICU?

Answer 6

Care of premature babies and pediatric patients

Question 7

What is a common reason for transporting ICU status patients?

Answer 7

Diagnostic and therapeutic interventions

Question 8

What percentage of the time does clinical management change during transport?

Answer 8

40%

Question 9

What imaging procedures are most likely to change treatment during transport?

Answer 9

Abdominal CT and Angiography

Question 10

What are some inherent risks of transporting critically ill patients?

Answer 10

• Hemodynamic/respiratory deterioration
• Inadequate monitoring/ability to maintain airway
• Interruption of medication administration

Question 11

What should you always bring when transporting a critically ill patient?

Answer 11

Pressors, sedation, relaxant, intubation supplies, AMBU Bag, full monitors, and BYO free flowing IV with ports for medication administration

Question 12

What are the criteria for bringing the ICU ventilator during transport?

Answer 12

FiO2 >40%, RR >18-20, PEEP >10 cm of H2O

Question 13

What is poikilothermia?

Answer 13

Inability to regulate temperature, manifested by hypo or hyperthermia

Question 14

What are some special considerations for spinal cord injury patients during transport?

Answer 14

• Displacement of fractures
• Movement of unstable C-Spine
• Pressure injury to limbs, eyes, and skin

Question 15

What is the leading cause of death and disability in traumatic brain injury?

Answer 15

Intubation may be necessary for patients with low GCS or evidence of aspiration

Question 16

What defines normal intracranial pressure (ICP)?

Answer 16

7-15 mmHg

Question 17

What is the cerebral perfusion pressure (CPP) formula?

Answer 17

CPP = MAP - ICP

Question 18

What should be the aim for CPP and ICP in neuro-resuscitation?

Answer 18

Aim for CPP of 60-70 mmHg and ICP <22 mmHg

Question 19

What is the most common cause of subarachnoid hemorrhage?

Answer 19

Rupture of saccular intracranial aneurysm

Question 20

What symptoms may indicate subarachnoid hemorrhage?

Answer 20

• Worst headache of my life
• Brief LOC
• Vomiting
• Neck pain/stiffness

Question 21

What is the management strategy for septic shock?

Answer 21

Use of vasopressors and lactate >2mmol/L despite sufficient fluid resuscitation

Question 22

What is the definition of shock?

Answer 22

Circulatory failure resulting in severe hypotension and inadequate tissue perfusion

Question 23

What are the subtypes of distributive or vasodilatory shock?

Answer 23

• Septic
• Anaphylactic
• Neurogenic

Question 24

What is a common treatment for cardiogenic shock?

Answer 24

Increase O2 supply and decrease oxygen demand

Question 25

What is the role of norepinephrine in shock management?

Answer 25

First-line drug providing potent vasoconstriction and modest CO increase

Question 26

What are the effects of dopamine at different doses?

Answer 26

* 1-2 mcg/kg/min - Primarily Dopamine-1 receptor, may increase urine output * 5-10 mcg/kg/min - Beta-1 increases SV and CO * >10 mcg/kg/min - Alpha vasoconstriction, increased SVR

Question 27

What does PPV stand for and what does it indicate?

Answer 27

Pulse Pressure Variation; a marker for position on the Frank-Starling curve

Question 28

What is the significance of hyperglycemia during cerebral ischemia?

Answer 28

It worsens acidosis and negatively impacts outcomes

Question 29

What is the treatment for traumatic brain injury with GCS <9?

Answer 29

Intubate to protect airway

Question 30

What is the goal SBP for patients with acute ischemic stroke?

Answer 30

Approximately 180 mmHg with pressor support

Question 31

What is the effect of hypothermia on metabolism?

Answer 31

Each degree Celsius lowers metabolism by 6-8%

Question 32

What is the importance of PACU care?

Answer 32

Early recognition and management of immediate post-op issues can be life saving. ## Footnote Quality of PACU Care is measured by time per patient, clinical outcomes, patient satisfaction, and complication rate.

Question 33

What is included in the initial handoff in the PACU?

Answer 33

Typically standardized review of patient history and OR course including: * Patient ID * Allergies * PMH * Important Home Meds * Preop meds * Access * Anesthetic Type * Airway Management * Antibiotics * Analgesics * Antiemetics * Other Meds * Intra-op problems * Ins and Outs * Anticipated Post-op Issues ## Footnote This ensures RN's questions are answered and they are comfortable taking over care.

Question 34

What defines Phase 1 in PACU units?

Answer 34

Monitoring and staffing ratios similar to ICU to ensure full recovery from anesthesia and return of vital signs to near baseline.

Question 35

What happens in Phase II of PACU?

Answer 35

Transition from intensive observation to stabilization for care on surgical floor or hospital discharge. Includes patient education about surgeon’s post-op instructions and any prescribed discharge meds.

Question 36

What are the discharge criteria in PACU?

Answer 36

Criteria include: * General Condition * Oriented x 3 * Adequate skeletal muscle strength * Absence of acute anesthesia/surgical issues * Cardiovascular stability * Ventilation and oxygenation * Airway maintenance * Pain adequately controlled * Renal Function intact * Ambulatory without dizziness * Controlled Post-op Nausea/Vomiting.

Question 37

What are the principal neurotransmitters that mediate Postoperative Nausea and Vomiting (PONV)?

Answer 37

The five principal neurotransmitters are: * Muscarinic M1 * Dopamine D2 * Histamine H1 * 5-hydroxytryptamine (HT)-3 serotonin * Neurokinin 1 (NK1).

Question 38

What are the risk factors for PONV?

Answer 38

Risk factors include: * Preop Nausea and Vomiting * Female Gender * History of PONV or motion sickness * Nonsmoking * Age < 50 * Chemotherapy-induced N/V.

Question 39

What is the most common reason for unexpected admission after outpatient surgery?

Answer 39

Postoperative Nausea and Vomiting (PONV).

Question 40

What is the recommended prevention strategy for PONV?

Answer 40

Multimodal/opioid sparing or opioid-free strategy when possible.

Question 41

What are the signs and symptoms of respiratory insufficiency in the PACU?

Answer 41

Signs include: * Tachypnea * Bradypnea * Hypoxemia * Anxiety * Confusion * Agitation.

Question 42

What are the common causes of inadequate ventilation postoperatively?

Answer 42

Common causes include: * Opioid-induced respiratory depression * Increased airway resistance * Decreased compliance * Residual neuromuscular blockade.

Question 43

What is the definition of postoperative hypotension?

Answer 43

A decrease of >20% from baseline blood pressure, which can result in organ hypoperfusion.

Question 44

What treatment options are available for postoperative hypotension?

Answer 44

Treatment options include: * Fluid bolus * Phenylephrine * Ephedrine * Norepinephrine * Vasopressin.

Question 45

What are the evaluation steps for postoperative hypotension?

Answer 45

Evaluation includes: * Assessing hypovolemia * Surgical blood loss * Ongoing bleeding * Inadequate fluid replacement.

Question 46

What are the potential treatments for airway edema?

Answer 46

Treatments include: * Glucocorticoids * Nebulized racemic epinephrine * Diuretics * Reintubation if edema persists.

Question 47

What is obstructive sleep apnea (OSA)?

Answer 47

Partial or complete obstruction of the upper airway leading to episodic desaturation, hypoxia, and hypercapnia.

Question 48

What are the risks associated with opioid administration in the PACU?

Answer 48

Opioids may cause respiratory depression and are associated with longer recovery times.

Question 49

What is the recommended dose of Naloxone?

Answer 49

40 mcg ## Footnote Naloxone is an opioid antagonist used to reverse opioid overdoses.

Question 50

What side effects may occur with higher doses of Dexmedetomidine?

Answer 50

Post op sedation, bradycardia, hypotension ## Footnote Dexmedetomidine is used for sedation but can cause significant cardiovascular effects.

Question 51

What is the treatment for hypotension due to sympathectomy from neuraxial anesthesia?

Answer 51

Discontinue infusion, pressors, volume resuscitation as necessary ## Footnote Sympathectomy can lead to severe hypotension, especially with high block levels.

Question 52

What is adrenal insufficiency and how is it treated?

Answer 52

Rare condition seen in chronic steroid users; treated with 100 mg hydrocortisone or 4 mg dexamethasone ## Footnote Patients may be resistant to pressors and fluids.

Question 53

What are the potential causes of hypotensive emergencies?

Answer 53

Shock of any etiology, local anesthetic systemic toxicity (LAST), tension pneumothorax, pulmonary embolus, LVOTO ## Footnote Each of these conditions requires immediate evaluation and treatment.

Question 54

What defines postoperative hypertension?

Answer 54

>20% increase in baseline BP ## Footnote This condition can lead to increased morbidity and mortality.

Question 55

What is the initial treatment for hypertension in the postoperative period?

Answer 55

Labetalol 5-10 mg, Metoprolol 1-5 mg, Hydralazine 5-10 mg ## Footnote Dosing depends on heart rate and previous treatment resistance.

Question 56

What symptoms may occur during alcohol withdrawal?

Answer 56

HTN, tachycardia, sweating, nausea, anxiety ## Footnote Symptoms may escalate to delirium tremens after 48-96 hours.

Question 57

What is a common cause of cardiac arrhythmias in the PACU?

Answer 57

Pain, hypovolemia, anemia ## Footnote Most arrhythmias are transient and not pathological.

Question 58

What is the treatment for severe bradycardia in the PACU?

Answer 58

Atropine 0.5 mg, may repeat up to 3 mg ## Footnote Treatment is indicated for symptomatic bradycardia.

Question 59

What are the risk factors for postoperative urinary retention?

Answer 59

Old age, male sex, history of urinary retention, prior pelvic surgery, neurologic disease ## Footnote Procedural and anesthetic factors also contribute.

Question 60

What is a common neuropsychiatric complication during emergence?

Answer 60

Emergence delirium ## Footnote Symptoms include agitation, disinhibition, and confusion, especially in pediatric patients.

Question 61

What is a potential treatment for emergence delirium?

Answer 61

Dexmedetomidine administration ## Footnote This medication helps to reduce hyperactive emergence delirium.

Question 62

What is Ischemic Optic Neuropathy (ION)?

Answer 62

A condition leading to partial or complete loss of vision ## Footnote Often related to surgical positioning or airway management.

Question 63

What can cause delayed emergence after anesthesia?

Answer 63

Residual neuromuscular blockade, prolonged drug effects, hypothermia ## Footnote Assessment of drug interactions and metabolism is crucial.

Question 64

What is the role of Physostigmine in the postoperative setting?

Answer 64

Reverses anticholinergic overdose effects ## Footnote Rarely needed but effective for scopolamine or atropine overdose.