PACU & Complications pt1 (Exam II)

Question 1

What is Standard 1 for postanesthesia care?

Answer 1

All patients who have received any type of anesthetic care should receive appropriate post-anesthetic care.

Question 2

What is Standard 2 for postanesthesia care?

Answer 2

Patient transported to PACU shall be accompanied by member of anesthesia team. Continually evaluated/treated/monitored throughout transport.

Question 3

What is Standard 3 for postanesthesia care?

Answer 3

Upon arrival to PACU the patient should be re-evaluated and a verbal report to PACU RN should be given by the anesthesia personnel.

Question 4

What is Standard 4 for postanesthesia care?

Answer 4

The patient shall be evaluated continually in the PACU.

Question 5

What is Standard 5 for postanesthesia care?

Answer 5

A physician is responsible for discharge of the patient from the PACU.

Question 6

What is the more intense phase of post-anesthetic recovery?

Answer 6

Phase 1

Question 7

In what phase are HR, O₂sat, RR, ECG, and airway patency monitored continuously?

Answer 7

Phase 1

Question 8

What has to be assessed if a patient is still intubated in the PACU?

Answer 8

Neuromuscular function

Question 9

How often must vital signs be assessed and recorded during the 1st phase of recovery? What is the target for vital management?

Answer 9

• q5 min for 1st 15 minutes
• q15 min for duration of phase 1.

Target vitals to 20% of baseline.

Question 10

What tools are used to determine patients criteria for discharge from PACU? (3)

Answer 10

• Standard Aldrete Score
• Modified Aldrete Score
• PACU Discharge Score

Question 11

Describe the Standard Aldrete Score.

Answer 11

A-R-C-C-S
0-2 score
0 = bad
2 = good

Question 12

Describe the Modified Aldrete Score.

Answer 12

Modified Aldrete Score
only difference is the saturation?

Question 13

Describe the Postanesthesia Discharge Score.

Answer 13

V-A-N/V-P-B
0-2 score

Question 14

What is the standard for how often vital signs must be checked in Phase II of recovery?

Answer 14

30 - 60 min

Question 15

What should be monitored in Phase II of recovery? (other than vital signs) (5)

Answer 15

• Airway and ventilation status
• Pain level
• PONV
• Fluid balance
• Wound integrity

Question 16

What are the most common complications that could be seen in the PACU?

Answer 16

Question 17

What are the causes (anatomically) of upper airway obstruction?

Answer 17

• Loss of pharyngeal muscle tone
• Paradoxical breathing

Question 18

What is the treatment of upper airway obstruction?

Answer 18

• Jaw thrust
• CPAP
• Oral/Nasal airway

Question 19

What are laryngospasms?

Answer 19

Vocal cord closure leading to loss of air movement, hypoxemia and negative pressure pulmonary edema.

Question 20

What are the three most common causes of laryngospasms?

Answer 20

• Stimulation of pharynx and/or vocal cords
• Secretions, blood, foreign material
• Regular extubations

Question 21

What is negative pressure pulmonary edema?

Answer 21

Non-cardiogenic pulmonary edema that results from high negative intrathoracic pressures attempting to overcome upper airway obstruction.

Question 22

What is the most common etiology of negative pressure pulmonary edema?

Answer 22

Laryngospasm

Occurs in 12% of laryngospasm cases.

Question 23

What is the physiology behind laryngospasm?

Answer 23

Prolonged exacerbation of glottic closure reflex due to superior laryngeal nerve stimulation.

Question 24

How would laryngospasms present upon inspection? (4)

Answer 24

• Faint inspiratory stridor
• Increased respiratory effort
• Increased diaphragmatic excursion
• Flailing of lower ribs

Question 25

At what pressure should the bag be squeezed when treating laryngospasm?

Answer 25

**Do not squeeze bag during laryngospasm**. Wait for pt to breath

Question 26

How should a BVM be utilized in laryngospasm emergency?

Answer 26

Apply facemask with tight seal and 100% FiO₂ and closed APL valve (~40 cmH₂O). ***Do NOT squeeze the bag***.

Question 27

What is the first step in treatment of laryngospasm?

Answer 27

Call for help

Question 28

What should be done after a BVM is utilized for laryngospasm? (4)

Answer 28

- Suction airway - Chin lift and/or jaw thrust - Oral/nasal airways - Laryngospasm notch pressure (larsons point)

Question 29

What is Larson's point? What is its significance?

Answer 29

Pressure point behind of the lobule of the pinna of each ear that can help relieve laryngospasm. Apply 3-5 seconds, release 5-10 seconds, maintain tight facemask seal.

Question 30

What will indicate a patient who is crumping out from your inability to break a laryngospasm?

Answer 30

- Tachycardia - Fast desaturation

Question 31

What should be done for a laryngospasm thats failed to respond to conventional treatment?

Answer 31

* Atropine, Propofol, Succinylcholine * Reintubate

Question 32

What initial dose of Succinylcholine is typically used for laryngospasm?

Answer 32

1/10 of normal dose (~0.1mg/kg)

Question 33

What neuromuscular blocking drug can cause bradycardia in pediatric patients.

Answer 33

Succinylcholine

Question 34

What would be noted on visual assessment that would indicate to the CRNA that a patient is developing airway edema?

Answer 34

Facial and scleral edema

Question 35

What two factors can precipitate airway edema?

Answer 35

- Prolonged intubation (especially in prone or trendelenburg cases). - Cases with ↑EBL (aggressive fluid resuscitation).

Question 36

What two things should be done prior to extubation with expected airway edema?

Answer 36

- Suction Oropharynx - ETT cuff leak test

Question 37

How is an ETT cuff leak test done?

Answer 37

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.

Question 38

When are airway hematomas most often seen? (3)

Answer 38

- Neck dissections - Thyroid removal - Carotid surgeries

Question 39

A rapidly expanding hematoma may precipitate ____________ edema.

Answer 39

supraglottic

Question 40

In the instance of airway hematoma, deviated tracheal rings and compression of the trachea below the ________ ________ are seen.

Answer 40

cricoid cartilage

Question 41

What is the treatment for airway hematoma post extubation? (4)

Answer 41

- Decompress airway be releasing surgical clips or sutures. - Remove SQ blood clot before reintubating - Reintubate - Surgical backup (tracheostomy)

Question 42

What surgeries and procedures is vocal cord palsy associated with? (4)

Answer 42

- ENT surgery - Thyroidectomy & parathyroidectomy - Rigid Bronchoscopy - Hyperinflated ETT cuff

Question 43

If vocal cord palsy is unilateral, then the patient is often ___________.

Answer 43

asymptomatic *pt may just sound hoarse, cough*

Question 44

How would damage to the external branch of the superior laryngeal nerve present? (3)

Answer 44

- Vocal weakness and "huskiness" - Paralyzed cricothyroid muscle - Loss of tension → vocal cord looks "wavy".

Question 45

What does bilateral Recurrent Laryngeal Nerve damage result in?

Answer 45

Aphonia & paralyzed vocal cords

Question 46

What position do the vocal cords assume with bilateral Recurrent Laryngeal Nerve damage?

Answer 46

Intermediate position (not adducted or abducted - midway).

Question 47

What is the biggest risk associated with bilateral Recurrent Laryngeal Nerve damage?

Answer 47

Airway obstruction during inspiration

Question 48

How long does it typically take for the hypocalcemia associated with thyroid surgery to present?

Answer 48

24 - 48 hours postop

Question 49

What is Chvostek's sign?

Answer 49

Facial spasm

Question 50

What is Trousseau's sign?

Answer 50

Carpal spasm w/ BP cuff