pulmonary embolis risk 1. venous stasis 2. hypercoagulabilty 3. abnormalities of the blood vessel wall

PACU Flashcards by Danielle Nies

Immediate PACU priority

respiratory and circulator adequacy

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Alderete score: Discharge from PACU protions

Able to move extremities on command
Breathing
Circulation
Consciousness
5.O2 sats

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Aldrete activity scoring

0: cannot move extremities or lift head
1: Moves 2 extremities voluntarily or on command and can lift head
2: Moves all extremities voluntarily or on command

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Aldrete respiration score

0: Apneic
1: dyspneic, shallow or inadequate
3: Normal, cough effective

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Aldrete Circulation score

0: BP>50 mmHg of preanesthetic vaclue
1: BP within 50 mmHg of preanesthetic value
2: BP within 20 mmHg

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Aldrete O2 sat scoring

0: SPO2 <90% on supplemental O2
1: SPO2 > 90% but needs supplemental O2
2: SPO2 > 92% RA

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Aldrete consciousness scoring

0: Unresponsive to voice
1: arousable to voice
2: fully awake

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Most common cause of airway obstruction in immediate postoperative phase

loss of pharyngeal muscle tone in sedated or obtunded patient

s/sx: snoring and use of accessory muscles

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Laryngeal obstruction

Occludes the airway from partial or complete spasm of intrinsic or extrinsic muscles of the larynx

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Laryngospasm can cause

negative pressure pulmonary edema

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Laryngospasm pathway

see notability

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Afferent laryngospasm

Internal branch SLN –> afferent limb–>brain

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Efferent laryngospasm

brain–>efferent limb–> External branch of SLN AND recurrent laryngeal nerve

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External branch of SLN innervates

Cricothyroid (elongates (tenses) vocal cords

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Recurrent laryngeal nerve innervates

Lateral cricoid
Thyroarytendoid

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Lateral cricoid does

ADDucts the vocal cords (closes glottis)

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Thyroarytenoid does

ADDucts the vocal cords (closes glottis)

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Muscular innervation of the vocal cords

SCAR
Superior laryngeal nerve = Cricothyroid muscles

All other muscles: Recurrent laryngeal nerve

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Extrinsic muscles

end in ‘-hyoid’

and digastric

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Treatment of laryngospasm

100% O2
Deepen anesthesia (propofol, lidocaine)
Larson manuever/vigorous jaw thrust/postive pressure ventilation
0.1 mg/kg succ
reintubation

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Larsons maneuver

bilateral digital pressure on styloid process behind posterior ramus of mandible

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laryngospasm drug treatments

propofol low dose 0.5 mg/kg
IV lidocaine
partial succs dose 0.1 mg/kg

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Virchows triad

pulmonary embolis risk

venous stasis
hypercoagulabilty
abnormalities of the blood vessel wall

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Bronchospasm cause

smooth muscle in airway inflammation

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bronchospasm treatment(5)

decrease airway irritability and promote bronchodilation Beta-2 agonist (i.e. albuterol) anticholinergics IV/inhaled lidocaine steroids

Causes of increased dead space postoperatively

1. PE (block alveoli) 2. deceased CO is most likely acute cause post op 3. ARDS/TRALI (destruction of pulmonary microvasculature, irreversible)

Causes of postoperative increased CO2

1. MH 2. Sepsis, fever

Best indicator of pulmonary oxygen transfer from alveolar gas to pulmonary capillary

PaO2 why are they not getting better?

PVO2 (mixed venous PO2) falls if

1. PaO2 decreases 2. Tissue extraction increases

What increases oxygen extraction (context: decreased PVO2)

Shivering, infection, hypertetabolism

What decreases tissue oxygen delivery (context: low PVO2)

Low CO and hypotension

Critical DO2

actual level at which shock occurs (lack of tissue oxygen delivery)

classic hypotension definition

<20% of baseline BP

Leading cause of post-operative hypertension

Pain somatic afferent nerve stim-->pressor response (somatosympathetic resonse)

with delerium, first:

always assume hypoxemia until proven otherwise

if delirium is not hypoxemia:

Treat with sedatives after hypoxemia has been eliminated as a cause midaz, propofol, dex most common

Main differentials for delayed emergence (3):

1. Drug-induced (not dex) 2. metabolic 3. neurologic (stroke, seizure, increased ICP)

Drug-induced delayed emergence(what drugs can be the cause)

Opioids Sedatives residual anesthetic inadequate NMB reversal

Metabolic delayed emergence

Hypoxia Hypercapnia/carbia hyponatremia acidosis hypo/er glycemia hypo/er thermia

Best measure of post op analgesia

patient perception

Hypothermia temp

below 36 degrees

What issues does hypothermia cause?

1. prolongs recovery 2. compromises physiologic stability 3.contributes to postoperative morbidity

Hypothermia: physiologic problems

1. Reduces O2 availability (shifts oxyhemoglobin curve to left) 2. shivering increase O2 demand by 400% 3. Drug biotransformation is decreased as metabolic dependent processes slow 4. Renal transport processes are slowed (decreased GFR) 5. Cardiac rate/rhythm disturbances (bradydysrythimias, PVCs) 6. CNS depressino 7. discomfort 8. increasing adrenergic stimulation 9. coagulopathy 10. Impaired wound healing, surgical site infection, increased hospital costs

Hypothermia prevention

Heated blankets Increase room temp fluid warmers warm irrigation

Shivering treatment

Rewarm small doses of: 1. meperidine 2. ketamine 3 dexmedetomidine 4. hydrocortison 5. granisetron 6. ondansatron

Primary risk factors for N/V

1. Female 2. less than 50 3. nonsmoker 4. hx PONV 5. hx motion sickness

Anesthetic risk factors for N/V

1.Use of volatiles 2. use of nitrous 3. higher doses of opioids used

Surgery related risk factors for N/V

1. duration > 1 hr 2. type of surgery (esp laparocscopy)

Classes of drugs that help PONV

1. 5-HT2 receptor antagonists 2. D2 dopamine receptor antagonists 3. Histamine receptro antagonists 4. NK-1 receptor antagonist 5. Dexametahsone 6. Ephedrine (keep BP up) 7. Antimuscarinic combination therapy is most effective

5-HT3 serotonin receptor antagonist drugs

1. ondansetron 2. dolasetron 3. granisetron 4. palonosetron

D2 dopamine receptor antagonist drugs

1. droperidol 2. Procholrperazine 3. metoclopramide

Histamine receptor antagonist drugs

1. diphenhydramine 2. promethazin 3. dimenhydrinate

Antimuscarinic drugs

1. glycopyrrolate 2. scopolamine

NK-1 receptor antagonist drugs

1. aprepitant

Non-pharmacologic PONV intervention

1. accupuncture 2. transcutaneous electrical nerve stim 3. acupoint stim 4. acupressure 5. aromatherapy - peppermint, alcohol 6. P6 stim (wrist)

Ondansatron timing

30 min before end of surgery

aprepitant timing

3 hrs before surgery

scopolamine timing

in preoperative holding area

Dexamethasone timing

shortly after anesthetic induction

Pt is oliguric. What is the FIRST aspect of perioperative care that should be evaluated

calculate fluid and blood product input and EBL

Urine output should be

0.5 mg/kg/hr

output/voiding and epidural/sinal

autonomic effects and interferes with sphincter relaxation-->urinary retention

PACU Flashcards

(63 cards)