Exam 2: PACU and other yikes things Flashcards
(107 cards)
1
Q
What is Standard 1 for postanesthesia care?
A
All patients who have received any type of anesthetic care should receive appropriate post-anesthetic care.
S4
2
Q
What is standard 2 for postanesthesia care?
A
A patient transported to the PACU shall be accompanied by a member of the anesthesia care team who is knowledgeable about the patient’s condition. The patient shall be continually evaluated and treated during transport with monitoring and support, appropriate to the patient’s condition.
S4
3
Q
What is Standard 3 for postanesthesia care?
A
Upon arrival to PACU the patient should be re-evaluated and a verbal report to RN should be given by the anesthesia personnel.
S5
4
Q
What is Standard 4 for postanesthesia care?
A
The patient shall be evaluated continually in the PACU.
S5
5
Q
What is Standard 5 for postanesthesia care?
A
A physician is responsible for discharge of the patient from the PACU.
S5
6
Q
What is the more intense phase of post-anesthetic recovery?
A
Phase 1
S16
7
Q
In phase 1, what are monitored continuously?
A
- HR
- SAT
- RR
- ECG
- airway patency
S16
8
Q
In phase 1, what are monitored frequently?
A
- Mental Status
- Blood pressure
- Temp
- pain
S16
9
Q
What has to be assessed if a patient is still intubated in the PACU?
A
Neuromuscular function
S16
10
Q
In phase 1, how often are vitals monitored and we want them within ____% of baseline
A
- vital signs:
- q5min for the first 15 min
- q15min for the duration of phase 1
we usually want the pts vitals within 20% of baseline
S17
11
Q
What tools are used to determine patients criteria for discharge from PACU? (happens in stage 2)
A
- Standard Aldrete Score
- Modified Aldrete Score
- PACU Discharge Score
S18
12
Q
Describe the Standard Aldrete Score, what are the 5 items it looks at?
A
- Activity
- Respiration
- Circulation
- Consciousness
- O2 sat
S19
13
Q
Describe the Modified Aldrete Score, and what is it usually used for?
A
Usually used for sedation cases
1. Activity
2. Respiration
3. Circulation
4. Consciousness
5. O2 sat
S20
14
Q
Describe the Postanesthesia Discharge Score.
A
- Vital signs (BP and pulse)
- Activity
- Nausea and vomiting
- Pain
- Surgical Bleeding
S21
A score of 10 is a perfect score
15
Q
What is the standard for how often vital signs must be checked in Phase II of recovery?
A
30 - 60 min
S22
16
Q
What 5 items should be monitored in Phase II of recovery? (other than vital signs)
A
- Airway and ventilation status
- Pain level
- PONV
- Fluid balance
- Wound integrity
S22
17
Q
What are the most common complications that could be seen in the PACU?
A
Top 3:
1. Overall (~22%)
2. N/V (~10%)
3. Upper airway support needed (~8%)
S24
18
Q
6 examples of Airway complications
A
- Airway obstruction
- Laryngospasm
- Airway Edema/hematoma
- Vocal Cord Palsy
- Residual Neuromuscular Block
- OSA
S26
19
Q
3 risk factors for airway complications
A
- Pt related: examples include COPD, OSA, obesity, HF, tobacco, URI and a high ASA
- Prodecure related: examples include surgery near diaphragm, ENT procedures, severe incisional pain, long procedure
- Anesthesia related: examples include GETA, NMBD, and opioids
S27
20
Q
Causes of upper airway obstruction
A
- Loss of pharyngeal muscle tone (biggest reason)
- Paradoxical breathing.
S28
21
Q
What is the treatment of upper airway obstruction?
A
- Jaw thrust (must keep holding)
- CPAP
- Oral/Nasal airway
S28
22
Q
What are laryngospasms?
A
Vocal cord closure leading to loss of air movement and hypoxemia and negative pressure pulmonary edema.
S29
23
Q
What are the three most common causes of laryngospasms?
A
- Stimulation of pharynx and/or vocal cords
- Secretions, blood, foreign material
- Regular extubations
S29
24
Q
What is negative pressure pulmonary edema?
A
Non-cardiogenic pulmonary edema that results from high negative intrathoracic pressures attempting to overcome upper airway obstruction.
S30
25
What is the most common etiology of negative pressure pulmonary edema?
Laryngospasm (or biting on the tube while trying to spont breathe)
*Occurs in 12% of laryngospasm cases*.
| S30
26
What is the physiology behind laryngospasm?
Prolonged exacerbation of glottic closure reflex due to **superior laryngeal nerve** stimulation.
| S31
27
What are the symptoms of a laryngospasm?
* Faint inspiratory stridor
* Increased respiratory effort
* Increased diaphragmatic excursion
* Flailing of lower ribs
FIRD
| S31
28
At what pressure should the bag be squeezed when treating laryngospasm?
**Do not squeeze bag during laryngospasm**.
| Lecture
29
How should a BVM be utilized in laryngospasm emergency?
Apply facemask with tight seal and 100% FiO₂ and closed APL valve to about 40cmH2O.
***Do NOT squeeze the bag***.
| S32
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What is the first step in treatment of laryngospasm?
Call for help
| S32
31
What should be done after a BVM is utilized for laryngospasm?
- Suction airway
- Chin lift and/or jaw thrust
- Oral/nasal airways
- Laryngospasm notch pressure
| S32
32
What is Larson's point?
What is its significance?
Pressure point behind of the lobule of the pinna of each ear that can help relieve laryngospasm.
*I.e. Laryngospasm notch*
| S33
## Footnote
Forcible jaw thrust with bilateral digital pressure resolves the spasm by clearing airway and stimulation.
Apply for 3-5 seconds, then release for 5-10 seconds, while maintaining tight seal with the facemask.
33
What will indicate a patient is crumping if you can't break a laryngospasm?
- Tachycardia
- Fast desaturation
| S35
34
What should be done for a laryngospasm thats failed to respond to conventional treatment?
Atropine, Propofol, Succinylcholine, reintubate.
| S35
35
What initial dose of Succinylcholine is typically used for laryngospasm?
0.1mg/kg of normal dose
| lecture
36
What neuromuscular blocking drug can cause bradycardia in pediatric patients.
Succinylcholine
| lecture
37
Airway edema is associated with...
* prolonged intubation
* long surgeries in the prone or T-Burg position
* Cases with large blood loss = agressive fluid resussitation
| S36
38
What would be noted on visual assessment that would indicate to the CRNA that a patient is developing airway edema?
Facial and scleral edema
| S36
39
What should be done prior to extubation with expected pulmonary edema?
- Suction Oropharynx
- ETT cuff leak test
| S37
40
How is an ETT cuff leak test done?
Remove small amount of air from cuff and assess for air movement around the cuff. If air cannot be heard then leave the tube in place.
| S37
41
When are airway hematomas most often seen?
- Neck dissections
- Thyroid removal
- Carotid surgeries
| S38
42
A rapidly expanding hematoma may precipitate ____ edema.
supraglottic
| S38
43
In the instance of airway hematoma, deviated tracheal rings and compression of the trachea below the ____ are seen.
cricoid cartilage
| S38
44
What is the treatment for airway hematoma post extubation?
- Decompress airway by releasing surgical clips or sutures.
- Remove SQ blood clot before reintubating
- Reintubate (have advanced airway equipment ready)
- Surgical backup (tracheostomy)
| S39
## Footnote
Corn says an awake intubation would be a good idea - a paralytic will relax the airway and collapse it more yikes
45
What surgeries and procedures is vocal cord palsy associated with?
- ENT surgery (orolaryngologic surgery)
- Thyroidectomy & parathyroidectomy
- Rigid Bronchoscopy
- Hyperinflated ETT cuff
| S40
46
If vocal cord palsy is unilateral, then the patient is often ___________.
asymptomatic
| S40
47
How would damage to the external branch of the superior laryngeal nerve present?
- Vocal weakness and "huskiness" (cords cannot tense up)
- Paralyzed cricothyroid muscle
- Loss of tension → vocal cord looks "wavy".
| S41
48
What does bilateral Recurrent Laryngeal Nerve damage result in?
Aphonia & paralyzed vocal cords
| S43
49
What position do the vocal cords assume with bilateral Recurrent Laryngeal Nerve damage?
Intermediate position (not adducted or abducted).
| S43
50
What is the biggest risk associated with bilateral Recurrent Laryngeal Nerve damage?
Airway obstruction during inspiration because the cords can close during inspiration (extrememly rare)
| S43
## Footnote
Corn says have a high index of suspition if the person can't talk
51
How long does it typically take for the hypocalcemia associated with thyroid surgery to present?
24 - 48 hours postop
| S46
52
What is Chvostek's and Trouseau's sign?
* Facial spasm
* Carpal spasm with BP cuff
| S46
53
What are some ways to assess for residual neuromuscular blockade?
- Grip strength
- Tongue protrusion
- Ability to lift legs
- Able to hold head up for 5 seconds
*just because you see these signs doesn't mean your patient's airway reflexes have returned*
| S47
## Footnote
meds can also contribute (lido drip or mag) can result in more weakness in PACU
54
What medication class are OSA patients sensitive to?
Opioids (try regional techniques for post-op pain)
| S48
55
What is the STOP-BANG assessing?
**S**nore
**T**ired
**O**bserved
**P**ressure
**B**MI > 35
**A**ge > 50
**N**eck circumference > 16 in
**G**ender (male)
| S49
56
What score on the STOP-BANG assessment is indicative of a low risk for OSA?
0 - 2
| S49
57
What score on the STOP-BANG assessment is indicative of a intermediate risk for OSA?
3 - 4
| S49
58
What score on the STOP-BANG assessment is indicative of a high risk for OSA?
5 - 8
| S49
59
What is the full STOP-BANG questionnaire?
| S49
60
What are common causes of arterial hypoxemia in a PACU patient?
- Room air
- Hypoventilation (too many pain meds, or benzos)
- OSA
| S50
## Footnote
Corn added OSA to the slide
61
What are common treatments for arterial hypoxemia in the PACU patient?
- O₂ with NC or mask
- Opioid/Benzo reversal
- Stimulate patient
| S50
62
What is Diffusion Hypoxia?
* Rapid diffusion of N₂O into alveoli at end of anesthetic. (second gas effect in reverse)
* Dilutes and decreases PaO₂ and PaCO₂ → hypoxemia w/ ↓ respiratory drive at room air.
*The decrease PaO2 produces arterial hypoximea while the PaCO2 depresses the resp. drive
| S51
63
How long can diffusion hypoxia persist after discontinuation of N₂O anesthetic?
5-10 min
*may contribute to arterial hypoxemia during phase 1 of PACU*
| S52
64
What are the standard treatment thresholds for hypertension in the PACU?
SBP > 180
DBP > 110
| S54
65
Common causes of systemic hypertension in the PACU
* Emergence excitement
* shivering
* **hypercapnia** (Corn highlighted this)
* Pain
* Agitation
* Bowel/abd distension (including insuflation pain)
* urinary retention
| S54
66
What medications (and doses) are typically used for treatment of systemic HTN in the PACU?
Labetalol (5 - 25mg)- HTN + Tachy
Hydralazine (5 - 10mg) - Okay with bradycardia
Metoprolol (1 - 5mg)- With HF patient, right?
*Dont forget to treat the underlying cause tho*
| S55
67
Hypotension that is due to decreased preload is ____.
Hypovolemic shock
| S56
68
Hypotension that is due to decreased afterload is ____
Distributive shock
| S56
69
Hypotension that is due to intrinsic pump failure is ____
Cardiogenic shock
| S56
70
What are four common causes of decreased preload?
- Third spacing
- Inadequate fluid replacement
- Neuraxial blockade → SNS tone loss (sympathetcomy)
- Bleeding
| S57
71
What are four common causes of decreased afterload?
- Sepsis
- Anaphylaxis
- Critical illness
- Iatrogenic sympathectomy
| S58
72
What are the two primary types of allergic reactions?
Anaphylactic & Anaphylactoid
*From Dr. Google: **Anaphylaxis** is an allergic reaction caused by the release of mediators from mast cells and basophils in response to an allergen (IgE). **Anaphylactoid** reactions are caused by the release of mediators from mast cells and basophils by non-IgE-mediated triggering events.*
| S60
73
What is the drug of choice for hypotension in an allergic reaction?
Epinephrine
| S60
74
What are the most common drug classes (and material) cause anaphylactic reactions?
Top 3:
1. Muscle relaxants! **most common is Roc**
2. Rubber/latex
3. Abx
| S60-61
75
Why would NMBD cause anaphylaxis?
* Engineered with quaternary ammonium ions (causes IgE allergic reactions)
| S62
76
Symptoms of allergeic reaction from NMBD
* vasodilation, erythema, edema, HoTN, GI constriction, tachycardia, pruritus etc
| S62
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We may not see the traditional allergic symptoms if our patient is asleep, what would we see and why?
* you will likely only see hemodynamic changes:
* Potent inflammatory leukotrienes (LTC) and prostaglandins (PGD) = **bronchial constriction & increased vascular permeability**
*look for increased airway pressures and hypotension*
| S62
78
What patient populations are at high risk for latex allergy?
- Repeated exposures (HCW's)
- Spina Bifida patients
- several surgical procedures
| S63
79
What are the three latex-mediated reactions?
- Irritant contact dermatitis
- Type IV cell-mediated reactions
- Type I IgE-mediated hypersensitivity reactions
| S63
80
What antibiotic causes a direct histamine release?
Vancomycin (but red man syndrome is not IgE mediated - histamine only)
| S64
81
What is the most common ABX allergy?
Penicillin
| S64
82
What two surgical procedures mentioned in lecture can lead to sudden sepsis?
Procedures involving urinary tract & biliary tract manipulation
| S65
83
Immediate treatment of sudden sepsis
* fluid resuscitaiton
* pressure support
| S65
84
What are the three most common causes of intrinsic pump failure?
- Myocardial ischemia/infarction
- Tamponade (pump fails because it can't fill)
- Dysrhythmias
| S66
85
What is the risk stratification guideline for non-cardiac surgery?
| S67
## Footnote
I feel like this is the 3rd class we have had to memorize this risk stuff for
86
What are factors that decrease myocardial O₂ supply?
| S69
87
What are factors that increase myocardial O₂ demand?
| S69
88
Causes of cardiac dysrhythmias
* Hypoxemia.
* Hypoventilation.
* Endogeneous and exogenous Catecholamine.
* Electrolyte abnormalities.
* Anemia.(not adequate o2 carrying capacity)
* Fluid overload.
| S70
89
What are the most common causes of sinus tachycardia?
- **SNS stimulation**
- **↓ volume**
- Anemia
- Shivering
- Agitation
| S71
90
Risk for atrial dysrhythmias is greatest after what types of surgeries?
Cardiac and Thoracic
| S72
91
What are risk factors for atrial dysthrythmias?
- Pre-existing cardiac conditions
- Hypervolemia
- Electrolyte abnormalities
- O₂ desaturation
| S72
92
Patients that are hemodynamically unstable due to atrial dysrhythmias require ____
cardioversion
*most pts will respond to B-blocker or calcium channel blockers*
| S73
93
What medications tend to work well for atrial fibrillation?
- β blockers
- CCBs
| S73
94
Greater than ____ ms QRS complex is considered wide.
120 ms
*PVCs are common but true Ventrucular tachycardia is rare and indicative of underylying cardiac pathyology*
| S74
95
What should be investigated with true ventricular tachycardia?
H's & T's
| S74
96
What procedures are associated with bradydysrhythmias?
- Bowel Distention from GI stuff
- ↑ ICP (Trendelenburg, etc.)
- ↑ Intraocular (eye sx's)
- Spinal Anesthesia
| S75
97
High spinals reaching the ____ level can block the cardioaccelerator fibers.
T1 - T4
*The combination of the sympathectomy, bradycardia, and lack of intravascular volume can produce cardiac arrest…even in young healthy patients.*
| S76
98
What risk factors for Postoperative Cognitive Dysfunction (POCD) were discussed in lecture?
- greater than 70 years old
- Pre-operative cognitive impairment
- ↓ Functional status
- EtOH abuse
| S79
99
What intra-operative factors are associated with POCD?
- Surgical blood loss (HCT < 30%, PRBC infusions)
- hypotension
- N2O administration (volatiles too)
- GETA
| S80
100
Differential for delayed awakening
* Eval vitals (hypercapnia)
* Neuro exam
* O2 stats
* BG eval
| S82
101
What is the #1 cause of delayed awakening?
Residual sedation from anesthetic
| S83
102
For delayed awakening secondary to opioids treat with ________ mcg of naloxone.
20 - 40 mcg
| S83
103
For delayed awakening secondary to benzodiazepines treat with ________ mg of flumazenil.
0.2mg
| S83
104
For delayed awakening secondary to scopolamine treat with ____ mg of ____
0.5 - 2mg IV Physostigmine.
| S83
105
What (besides residual sedation) are some common reasons for delayed awakening from anesthesia?
- Hypothermia < 33°C
- ↓BG
- ↑ICP
- Residual NMBD's
| S84
106
What are some basic recommendations for discharge from PACU?
| S85
107
What is/are the criteria for Determination of Discharge from PACU Score?
| S86
