What are the 5 standards for postanesthesia care?
- all patients receiving anesthesia should receive appropriate postanesthesia management
- anesthesia care team member must escort patient to PACU
- verbal report must be provided to PACU RN by member of anesthesia care team
- patient should be continuously monitored in PACU
- physician is responsible for discharge of patient from PACU
When were PACU’s first opened in the US?
1920
When did PACU become a standard of care? Why?
in 1949 (an 11 year study showed 50% of deaths in the first 24 hours following surgery were preventable)
How long is phase 1 of recovery and how often do you need to chart vitals?
At least 30 minutes total
Vitals q5 min for 1st 15 min
How long is phase 2 of recovery and how often do vitals need to be charted?
vitals q30-60 min
from the end of phase 1 thru discharge
What criteria do patients need to meet to be discharged?
An Aldrete score of 9 or 10
What are the 5 criteria measured in the Aldrete score?
activity
respiration
circulation
consciousness
oxygen saturation
What are the three most common complications of anesthesia?
nausea and vomiting
need for upper airway support
hypotension
List a few airway complications…
obstruction
laryngospasm
airway edema
vocal cord palsy
residual NMBlockade
OSA
What are some treatments for upper airway obstruction?
jaw thrust
continuous positive pressure
oral/nasal airway
What major complication can laryngospasms lead to?
negative pressure pulmonary edema
What is the treatment for laryngospasm?
Apply facemask with a tight seal. Give 100% FiO2, close APL valve to 40 cmH2O and wait for patient to breathe (do NOT squeeze the bag)
Where is the laryngospasm notch?
Larson’s point - behind the lobule of the pinna in each ear - apply firm pressure here and perform a jaw thrust to break a laryngospasm
What will you see if you are unable to break the laryngospasm? What should you do?
patient is rapidly desaturate and HR will increase
give atropine, propofol and succ (re-intubate)
What are some risk factors for airway edema?
prolonged intubation, long surgical procedures
prone and Trendelenburg positions
aggressive fluid resuscitation
What are some things that can alert the CRNA that the patient likely has airway edema?
facial and scleral edema
How can you assess for airway edema?
perform a ETT cuff leak test, if you cannot hear the passage of air, leave the tube in place
Which procedures are at greatest risk for airway hematomas?
neck dissections, thyroid removal and carotid surgeries
How do you treat an airway hematoma?
surgeon needs to release clips or sutures to decompress and clot needs to be removed
CRNA may need to reintubate and have advanced airway equipment ready, may need to a tracheostomy
Which surgeries are most associated with vocal cord palsy?
otolaryngologic surgery, thyroidectomy, parathyroidectomy, rigid bronchoscopy or d/t overinflated ETT cuff
What type of vocal cord paralysis is often asymptomatic?
unilateral vocal cord paralysis
Damage to what nerve can lead to cricothyroid muscle weakness and hoarseness of voice?
the external branch of the superior laryngeal nerve
What are a few complications of thyroid surgery?
hypocalcemia
hematoma formation
recurrent laryngeal nerve damage
What are the two textbook symptoms of hypocalcemia?
Chvostek’s sign (facial spasms)
Trousseau’s sign (carpal spasms from BP cuff inflation)
