Postanesthesia Care (based on Morgan)

Question 1

Formerly anesthetized patients should not leave the operating room unless they have a patent airway, have adequate ventilation and oxygenation, and are hemodynamically stable; qualified anesthesia personnel must also be available to attend the transfer.

Answer 1

True

Question 2

Before the recovering patient is fully responsive, pain is often manifested as postoperative restlessness. What are some serious systemic disturbances that must be considered in the differential diagnosis of postoperative agitation?

Answer 2

Hypoxemia, respiratory or metabolic acidosis, or hypotension

Question 3

Intense shivering causes precipitous rises in oxygen consumption, CO2 production, and cardiac output. These physiological effects are often poorly tolerated by patients with what condition?

Answer 3

Preexisting cardiac or pulmonary impairment

Question 4

Respiratory problems are the most frequently encountered serious complications in the postanesthesia care unit (PACU). What are the most common causes?

Answer 4

Airway obstruction, hypoventilation, and/or hypoxemia

Question 5

Hypoventilation in the PACU is most commonly due to what?

Answer 5

Residual depressant effects of anesthetic agents on respiratory drive

Question 6

Obtundation, circulatory depression, or severe acidosis (arterial blood pH < 7.15) indicates what kind of intervention?

Answer 6

Immediate and aggressive respiratory and hemodynamic intervention, including airway and inotropic support

Question 7

Following naloxone administration, what should be closely monitored in patients?

Answer 7

Recurrence of opioid-induced respiratory depression (‘renarcotization’) due to naloxone’s shorter duration compared to opioids

Question 8

Increased intrapulmonary shunting from a decreased functional residual capacity relative to closing capacity is the most common cause of what post-anesthesia condition?

Answer 8

Hypoxemia following general anesthesia

Question 9

What surgical complications should be considered following central line placement, intercostal blocks, and certain abdominal or chest trauma procedures?

Answer 9

Postoperative pneumothorax

Question 10

What is the most common cause of hypotension in the PACU?

Answer 10

Hypovolemia

Question 11

What typically causes postoperative hypertension in the PACU?

Answer 11

Noxious stimulation from incisional pain, endotracheal intubation, or bladder distention

Question 12

Why was specialized nursing care emphasized in the immediate postoperative period after World War II?

Answer 12

Many early postoperative deaths occurred immediately after anesthesia and surgery, and many were preventable. A nursing shortage and experience treating large numbers of battle casualties contributed to the trend of centralization in recovery rooms.

Question 13

What percentage of all surgical procedures in the United States are now performed on an outpatient basis?

Answer 13

More than 70%

Question 14

What is the difference between Phase 1 and Phase 2 recovery in outpatient surgery?

Answer 14

Phase 1 is the immediate intensive care recovery, and Phase 2 is a lower-level care for readiness to go home

Question 15

How must the PACU be equipped to handle patients undergoing procedures such as central line placement, electroconvulsive therapy, and elective cardioversion?

Answer 15

It must be appropriately staffed and equipped to manage these patients and their potential complications.

Question 16

Why should the PACU be located near operating rooms and off-site invasive procedure areas?

Answer 16

To ensure quick access in case patients need urgent surgery or care

Question 17

Which equipment is mandatory in every PACU patient space?

Answer 17

Pulse oximetry, electrocardiogram, and automated noninvasive blood pressure monitors

Question 18

Why is the PACU required to have its own supplies of emergency equipment?

Answer 18

To manage potential complications during the recovery of surgical patients

Question 19

What kind of staff is required for the PACU?

Answer 19

Nurses specifically trained in anesthesia recovery, airway management, advanced cardiac life support, and common postoperative issues

Question 20

What is the general ratio of recovery nurses to patients in a high-volume surgical institution PACU?

Answer 20

One recovery nurse for two patients

Question 21

Which medical professionals are involved in the coordinated management of PACU patients?

Answer 21

Anesthesiologists, surgeons, nurses, respiratory therapists, and appropriate consultants

Question 22

How does the use of a Bispectral Index Scale (BIS) monitor impact recovery?

Answer 22

It may reduce total drug dosage and shorten recovery time

Question 23

What is the most frequent cause of delayed emergence from general anesthesia?

Answer 23

Residual anesthetic, sedative, and analgesic drug effects

Question 24

How is delayed emergence treated in cases of opioid or benzodiazepine overdose?

Answer 24

Naloxone (for opioids) and flumazenil (for benzodiazepines)

Question 25

What uncommon causes of delayed emergence should be considered?

Answer 25

Hypothermia, metabolic disturbances, and perioperative stroke

Question 26

How should formerly anesthetized patients be transported from the operating room to the PACU?

Answer 26

They must have a patent airway, adequate ventilation, and oxygenation, and be hemodynamically stable. Qualified anesthesia personnel must attend the transfer.

Question 27

What should be done if a patient at risk of hypoxemia is transported from the operating room?

Answer 27

Supplemental oxygen should be administered during transport.

Question 28

How should patients with pulmonary dysfunction or at risk for vomiting be transported?

Answer 28

Patients should be transported in a lateral position to prevent airway obstruction and facilitate drainage of secretions.

Question 29

What must be assessed immediately upon PACU arrival after general anesthesia?

Answer 29

Airway patency, vital signs, oxygenation, and level of consciousness.

Question 30

How frequently are vital signs measured in the PACU after general anesthesia?

Answer 30

At least every 5 minutes for 15 minutes or until stable, and every 15 minutes thereafter.

Question 31

Which monitoring should be continuous for all patients recovering from general anesthesia?

Answer 31

Pulse oximetry.

Question 32

What should be assessed clinically to monitor neuromuscular function?

Answer 32

Head-lift and grip strength.

Question 33

What must be included in the anesthesia provider's report to the PACU nurse?

Answer 33

Preoperative history, intraoperative events, expected postoperative problems, PACU medication administration, and postanesthesia orders.

Question 34

Why is supplemental oxygen used in patients recovering from general anesthesia?

Answer 34

To prevent transient hypoxemia, which can develop even in healthy patients.

Question 35

How should oxygen therapy be controlled in patients with chronic obstructive pulmonary disease?

Answer 35

Carefully controlled to avoid CO2 retention.

Question 36

What is the recommended patient position during recovery from general anesthesia to optimize oxygenation?

Answer 36

Patients should be nursed in the back-up position, whenever possible.

Question 37

What should be monitored in patients recovering from regional anesthesia?

Answer 37

Sensory and motor levels, blood pressure, and potential bladder catheterization.

Question 38

How should postoperative pain be controlled for moderate to severe pain?

Answer 38

Oral or parenteral opioids.

Question 39

What are some opioid-sparing strategies for postoperative pain management?

Answer 39

Preoperative administration of NSAIDs, acetaminophen, gabapentin, and postoperative local anesthetic modalities.

Question 40

What are the most common medications for mild to moderate postoperative pain?

Answer 40

Acetaminophen, ibuprofen, hydrocodone, or oxycodone.

Question 41

How should opioids be administered for moderate to severe pain in the PACU?

Answer 41

Parenteral or intraspinal opioids, single-shot or continuous nerve blocks, or continuous epidural analgesia.

Question 42

What is the effect of epidural fentanyl or sufentanil on postoperative pain?

Answer 42

It provides excellent pain relief.

Question 43

What should be done to manage postoperative agitation before the patient is fully responsive?

Answer 43

Consider causes like hypoxemia, acidosis, or a surgical complication, and treat with sedation if necessary.

Question 44

How should postoperative nausea and vomiting (PONV) be prevented?

Answer 44

Use of 5-HT3 antagonists like ondansetron, granisetron, or dolasetron.

Question 45

Which risk factors are associated with increased PONV?

Answer 45

Young age, female gender, history of postoperative emesis, and surgeries like laparoscopy or breast surgery.

Question 46

How can hypothermia-induced shivering be treated in the PACU?

Answer 46

Use a forced-air warming device or administer small doses of meperidine.

Question 47

Which conditions may cause postoperative shivering besides hypothermia?

Answer 47

Bacteremia, sepsis, drug allergy, or transfusion reaction.

Question 48

What criteria should be met before discharge from the PACU?

Answer 48

Easy arousability, full orientation, stable vital signs, no surgical complications, and controlled pain and nausea.

Question 49

What additional factors must be considered when discharging patients after regional anesthesia?

Answer 49

Regression of both sensory and motor blockade.

Question 50

What is the typical discharge process for outpatient surgery?

Answer 50

Patients are fast-tracked to phase 2 recovery and must be accompanied by a responsible adult.

Question 51

What is the primary assessment for home readiness following outpatient surgery?

Answer 51

Proprioception, sympathetic tone, bladder function, and motor strength recovery.

Question 52

How long does complete psychomotor recovery usually take for outpatient surgery?

Answer 52

24–72 hours.

Question 53

What are the most common respiratory complications in the PACU?

Answer 53

Airway obstruction, hypoventilation, and hypoxemia.

Question 54

What is the most common cause of airway obstruction in unconscious patients?

Answer 54

The tongue falling back against the posterior pharynx.

Question 55

What maneuvers can be used to alleviate partial airway obstruction?

Answer 55

Jaw-thrust and head-tilt maneuver, and insertion of an oral or nasal airway.

Question 56

What is the initial management of laryngospasm in the PACU?

Answer 56

Jaw-thrust maneuver with gentle positive airway pressure, and insertion of an oral or nasal airway.

Question 57

What should be administered for refractory laryngospasm?

Answer 57

Small dose of intravenous succinylcholine (10-20 mg in adults) and positive-pressure ventilation with 100% oxygen.

Question 58

What medication can be used to treat glottic edema following airway instrumentation in infants and young children?

Answer 58

Intravenous corticosteroids (dexamethasone, 0.5 mg/kg) or aerosolized racemic epinephrine (0.5 mL of 2.25% solution with 3 mL saline).

Question 59

How should post-operative wound hematomas affecting the airway be managed?

Answer 59

Immediate opening of the wound to relieve tracheal compression.

Question 60

How should accidental decannulation of a fresh tracheostomy be managed?

Answer 60

Only performed with a qualified surgeon at the bedside, with appropriate airway equipment immediately available.

Question 61

How is hypoventilation defined in terms of Paco2?

Answer 61

Hypoventilation is generally defined as Paco2 >45 mm Hg.

Question 62

What are common signs of significant hypoventilation in the PACU?

Answer 62

Excessive somnolence, slow respiratory rate, tachypnea with shallow breathing, or labored breathing.

Question 63

What is the primary cause of hypoventilation in the PACU?

Answer 63

Residual depressant effects of anesthetics on respiratory drive.

Question 64

How should opioid-induced respiratory depression be managed?

Answer 64

Titration of naloxone in small increments (80 mcg in adults) to reverse hypoventilation without significantly reversing analgesia.

Question 65

What is the first-line treatment for significant hypoventilation in the PACU?

Answer 65

Assisted or controlled ventilation until the underlying cause is identified and corrected.

Question 66

What are some causes of residual muscle paralysis in the PACU?

Answer 66

Inadequate reversal, pharmacological interactions, altered pharmacokinetics, metabolic factors like hypokalemia or respiratory acidosis.

Question 67

How is residual paralysis diagnosed in unconscious patients?

Answer 67

With a nerve stimulator.

Question 68

What should be done if residual paralysis is present despite a full dose of a cholinesterase inhibitor?

Answer 68

Controlled ventilation under close observation until spontaneous recovery occurs.

Question 69

What is the usual cause of hypoxemia in the PACU?

Answer 69

Hypoventilation, increased right-to-left intrapulmonary shunting, or both.

Question 70

What is the common cause of hypoxemia following general anesthesia?

Answer 70

Decreased functional residual capacity (FRC) relative to closing capacity.

Question 71

What should be done to treat hypoxemia in the PACU?

Answer 71

Oxygen therapy with or without positive airway pressure, and other measures based on the underlying cause.

Question 72

What are common causes of hypoxemia due to hypoventilation?

Answer 72

Marked hypercapnia or concomitant intrapulmonary shunting.

Question 73

What is the management of postoperative hypoxemia due to a pneumothorax?

Answer 73

Chest tube or Heimlich valve insertion for symptomatic pneumothorax.

Question 74

How should postoperative pulmonary edema be managed?

Answer 74

Diuretics and optimization of cardiac function.

Question 75

What is the treatment for significant hypotension in the PACU?

Answer 75

Fluid bolus (250–500 mL crystalloid or 100–250 mL colloid), and vasopressors/inotropes (dopamine or epinephrine) if needed.

Question 76

What are the signs of cardiac dysfunction in the PACU?

Answer 76

Signs include failure to respond to fluid bolus, and may require invasive hemodynamic monitoring or echocardiographic examination.

Question 77

What is the immediate management of hypotension due to a tension pneumothorax?

Answer 77

Immediate pleural aspiration, even before radiographic confirmation.

Question 78

What are common causes of postoperative hypertension in the PACU?

Answer 78

Incisional pain, endotracheal intubation, bladder distention, or the neuroendocrine stress response.

Question 79

What is the treatment for mild postoperative hypertension in the PACU?

Answer 79

Mild hypertension generally does not require treatment, but a reversible cause should be sought.

Question 80

What is the treatment for severe postoperative hypertension in the PACU?

Answer 80

Intravenous β-blockers (labetalol, esmolol), ACE inhibitors (enalapril), or calcium channel blockers (nicardipine), or intravenous infusion of nitroprusside or other vasodilators for patients with limited cardiac reserve.

Question 81

What are common arrhythmias seen in the PACU?

Answer 81

Bradycardia, tachycardia, premature atrial and ventricular beats, and supraventricular tachyarrhythmias.

Question 82

What is the cause of bradycardia in the PACU?

Answer 82

Residual effects of cholinesterase inhibitors, opioids, or β-adrenergic blockers.

Question 83

What can cause tachycardia in the PACU?

Answer 83

Anticholinergic agents, β-agonists (like albuterol), reflex tachycardia from hydralazine, pain, fever, hypovolemia, and anemia.

Question 84

What is the treatment for premature atrial or ventricular beats in the PACU?

Answer 84

Correction of underlying causes such as hypokalemia, hypomagnesemia, or ischemia.

Question 85

What are the perioperative causes of tachycardia?

Answer 85

Anxiety, Pain, Fever, Hypoxemia, Hypercapnia, Hypotension, Anemia, Hypovolemia, Congestive heart failure, Cardiac tamponade, Tension pneumothorax, Thromboembolism, Antimuscarinic agents, β-Adrenergic agonists, Vasodilators, Allergy, Drug withdrawal, Hypoglycemia, Thyrotoxicosis, Pheochromocytoma, Adrenal (addisonian) crisis, Carcinoid syndrome, Acute porphyria

Question 86

What are the perioperative causes of fever?

Answer 86

Infections, Immunologically mediated processes, Drug reactions, Blood reactions, Tissue destruction (rejection), Connective tissue disorders, Granulomatous disorders, Tissue damage (Trauma, Infarction, Thrombosis), Neoplastic disorders, Metabolic disorders (Thyroid storm, Adrenal (addisonian) crisis, Pheochromocytoma, Malignant hyperthermia, Neuroleptic malignant syndrome, Acute gout, Acute porphyria)

Question 87

What should be done if a young adult male with a femur fracture shows persistent tachycardia and fever?

Answer 87

Evaluate the causes of tachycardia and fever (possible thyrotoxicosis, infection, pain, anxiety, hypovolemia, etc.), and assess further with appropriate investigations like chest X-ray, arterial blood gas, and thyroid hormone levels. Delay surgery until a diagnosis is clear.

Question 88

What is the most likely cause of tachycardia and fever in the young adult male with a femur fracture?

Answer 88

Possible causes include infection (e.g., wound, pulmonary, or urinary), pain, anxiety, hypovolemia, pulmonary fat embolism, or thyrotoxicosis (suggested by enlarged thyroid).

Question 89

What additional measures should be taken to evaluate tachycardia and fever in the young adult male with a femur fracture?

Answer 89

Arterial blood gas measurement, chest film, repeat hematocrit or hemoglobin, fluid challenge, sedation, thyroid hormone measurement, and cultures if infection is suspected.

Question 90

What is the likely diagnosis for a patient showing excessive adrenergic activity, fever, increased fluid needs, and delirium after surgery?

Answer 90

Thyroid storm, a hypermetabolic state caused by severe thyrotoxicosis, with a high mortality rate if untreated.

Question 91

What are the key features of thyroid storm?

Answer 91

Fever, tachycardia, hypotension, delirium or coma, atrial and ventricular arrhythmias, heat intolerance, nausea, vomiting, diarrhea, and hypokalemia. Often precipitated by stressors like surgery.

Question 92

What is the management for thyroid storm?

Answer 92

Corticosteroids, propylthiouracil, iodine, propranolol, supportive care with cooling blankets, acetaminophen, and fluid replacement. Vasopressors may be needed for hypotension. β-blockers should be used cautiously in congestive heart failure.

Question 93

What is the significance of β1 and β2 blockade in thyroid storm?

Answer 93

Combined β1- and β2-blockade is preferred because β2-blockade reduces muscle blood flow and metabolic heat production. It also helps in controlling adrenergic symptoms, including tachycardia and hypertension.

Question 94

What is the role of propranolol in managing thyroid storm?

Answer 94

Propranolol antagonizes the peripheral effects of thyrotoxicosis and inhibits the peripheral conversion of T4 to T3, which is helpful in controlling symptoms.

Question 95

What is the management approach if a thyroid storm patient is in atrial fibrillation?

Answer 95

Ventricular rate control with β-blockers, and possible echocardiography or hemodynamic monitoring for patients with signs of heart failure or persistent hypotension.

Question 96

Why is esmolol administered during surgery in patients with tachycardia?

Answer 96

Esmolol is used to decrease tachycardia and manage adrenergic symptoms by providing short-acting β-blockade.

Question 97

What are the signs that suggest thyroid storm after surgery?

Answer 97

Mental status changes, excessive adrenergic activity, worsening fever, and signs of hypotension or arrhythmias despite fluid resuscitation and medications.