1
Q
The ______ creates the standards to be followed in regards to the PACU for CRNA’s
A
AANA
2
Q
What is standard 1 for post anesthesia care?
A
All pts who received GA, regional or monitored anesthesia shall receive appropriate post anesthesia management
3
Q
What is standard 2 for post anesthesia care?
A
A pt 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 w/ monitoring & support, appropriate to the patient’s condition.
4
Q
What is standard 3 for post anesthesia care?
A
Upon arrival to the PACU, the pt shall be reevaluated & verbal report provided to the responsible PACU RN by the member of the anesthesia care team who accompanies the pt
5
Q
What is standard 4 for post anesthesia care?
A
The pt’s condition should be evaluated continually in the PACU
6
Q
What is standard 5 for post anesthesia care?
A
A physician is responsible for the discharge of the patients from the PACU
7
Q
In CRNA only practices, who is responsible for the discharge from the PACU?
A
The surgeon
8
Q
PACU’s opened in _______ and became a standard of care in _______
A
1920
1949
9
Q
Who are the staff members in the PACU? (4)
A
- Specially trained PACU RN
- Respiratory therapist
- Anesthesia personnel
- Intensivist/hospitalist
10
Q
There is always at least 1 __________ assigned to the PACU. How does this work? (2) what is the role of the hospitalist/intensivist in the PACU?
A
Anesthesia personnel
- 1 may cover the entire PACU
- CRNA may cover their own pts in the PACU
Role of hospitalist/intensivist: help to cover in place of anesthesia
11
Q
T/F: the PACU is always close to the OR
A
F
No, sometimes the PACU can be further away from the OR depending on what type of hospital you’re in. And it can also be on a different floor.
12
Q
What type of monitoring devices would you need for travel to the PACU? (3)
A
- Oxygenation – SPO2
- Ventilation – Ambu bag
- Circulation – BP & HR
13
Q
What do you do upon arrival to the PACU? (4)
A
- Connect pt to PACU monitors
- Assess pt four airway patency, vitals, mental status, PONV
- Assess/Tx hypoxemia
- Give PACU RN report
14
Q
The CRNA report to the PACU RN needs to be _________ (2) & completed when you have the ______ of the receiving RN
A
- Specific
- Organized
Full attention
15
Q
What are tools used by CRNAS to PACU RN report? (3)
A
- SBAR
- Simplified hanoff tool
- PACU admission report
16
Q
What are the benefits to SBAR? (3)
A
- Standardized
- Covers surgical & patient factors
- Easy to remember
17
Q
What do you always ask at the end of giving a report to the PACU RN?
A
Do you have any questions?
18
Q
Who is present when doing report when bringing the pt from the OR to the ICU? (3)
A
- ICU RN
- Member of the surgical team
- Member of the anesthesia care team
19
Q
T/F: significant gaps can happen in report when pt is going from the OR to the ICU
A
T
20
Q
Phase 1 of PACU recovery is ______ intense. Vitals are monitored every ______ for the 1st ______, then every _______ for the duration of phase 1. Describe this phase.
A
More
5 mins
15 mins
15 mins
- Heart rate, SPO2, RR, ECG, airway patency, mental status, BP, Temp are monitored continuously/frequently
- intubated = neuromuscular functioning will be monitored
21
Q
In phase 1, they want to keep the pt’s vitals within _______ of baseline.
A
20%
22
Q
T/F: Pts have to go to phase 1 and phase 2 before being d/c home
A
F
They can go directly to phase 2 then home.
23
Q
You are required to go to PACU phase I if you have ______. You are required to spend ______ in either phase.
A
GA
30 mins
24
Q
In PACU phase II, vitals are taken every ________. What is being monitored here? (5) What is the purpose of PACU phase II?
A
30 - 60 minutes
- Airway/ventilation status
- Pain level
- PONV
- Fluid balance
- Integrity of wound
Being prepped for d/c to go home
25
What are tools used in phase 2 of PACU recovery for pt criteria for d/c? (3) Which is most common?
1. **Standard Aldrete score** (Most common)
2. Modified Aldrete score
3. Post anesthesia discharge score
26
Which PACU discharge scoring criteria doesn't just focus on anesthesia only? What does it include?
Post anesthesia discharge scoring system
Has a score for **surgical bleeding** as well
27
What are common **airway complications** seen in the PACU? (6)
1. Airway obstruction
2. Laryngospasm
3. Airway edema/hematoma
4. Vocal cord palsy
5. Residual neuromuscular block
6. OSA
28
What are **patient-related** factors that increase the risk for airway complications in the PACU? (9)
1. COPD
2. Asthma
3. OSA
4. Obesity
5. HF
6. Pulmonary HTN
7. Upper respiratory tract infection
8. Tobacco use
9. Higher ASA score
29
What are **procedure related** factors that increase the risk for airway complications in the PACU? (5)
1. Sx near diaphragm
2. ENT procedures
3. Severe incisional pain
4. IV fluids
5. Long procedures (3 hrs)
30
Procedure near the ________ (2) impaired pulmonary function
1. Thoracic
2. Abdomen
31
How does pain affect pulmonary function? (2)
1. If it hurts to breathe --> they won't take full breath in
2. Increase pain = increase opioids = increased respiratory depression
32
What are **anesthesia related** factors that increase the risk for airway complications in the PACU? (3)
1. GA
2. Muscle relaxers
3. Opioids
33
What type of effect does magnesium have on paralytics?
Magnesium can prolong paralytics
34
If the pt is a high risk of obstruction, what should we do before leaving the OR on the way to the PACU?
Insert oral airway
35
What are causes of upper airway obstruction in the PACU? (2)
1. Loss of pharyngeal tone
2. Paradoxical breathing
36
What is the Tx for upper airway obstruction in the PACU? (3)
1. Jaw thrust
2. Continuous positive airway pressure (CPAP)
3. Oral/nasal airway
37
How would you define Laryngospasm? What are symptoms? (3) What causes this? (3) What can this result in? (2)
Define: **vocal cords close** & prevent any air movement
Symptoms:
1. Faint inspiratory stridor dt increase respiratory effort
2. Increase diaphragmatic excursion
3. Flailing of lower ribs
Causes:
1. Stimulation of the **superior laryngeal nerve** dt:
2. Secretions, blood, foreign materials
3. Regular extubations
Results:
1. Hypoxemia
2. Negative pressure pulmonary edema
38
Negative pressure pulmonary edema is a form of ___________ that results from a generation of __________ intrathoraric pressure needed to overcome upper airway obstruction.
Non-cardiogenic pulmonary edema
High, negative
39
Negative pressure pulmonary edema happens about ____% of the time, and is a common result of a _______. how long does it normally take to resolve?
12%
Laryngospasm
12-48hrs
40
What should you always do when treating a laryngospasm? What is the Tx for Laryngospasms? (3)
SUCTION THE AIRWAY!!!!!!!
1. Apply pressure:
-APL = 40 cmH20 & wait for pt to breath
2. Chin lift/jaw thrust
3. Pressure on laryngospasm notch (Larson's point)
41
Pressure on Laryngospasm notch =
Larson's maneuver
42
Where is Larson's point?
Behind the lobule of the pinna of each ear
43
What is Larson's Maneuver? How do you do it?
Forceable job thrust w/ bilateral pressure to resolve a laryngospasm (Also called laryngospasm notch)
Applied pressure for 3 - 5 secs on Larson's point --> release for 5 - 10 secs while maintaining tight seal w/ face mask
44
What symptoms will your pt display if you cannot break a laryngospasm? (2)
1. Fast desaturation
2. Increased HR
45
What should you do if you cannot break a laryngospasm? (4)
Medicate:
1. Atropine (for brady)
2. Propofol
3. Succs
Next:
4. Re-intubate
46
Airway edema is associated with/ prolonged intubation/sx in ________ (2) positions. What else causes this? What is a hallmark sign of airway edema?
1. Prone
2. Trendelenburg
Agressive fluid resuscitation (large blood loss)
Hallmark:
Facial & scleral edema = airway edema
47
What is a cuff leak test? Why is it relevant?
Suction oral pharynx --> remove small amount of air from ETT cuff --> assess for air moving around cuff
If you cannot hear air --> leave tube in place = airway edema & unsafe to extubate.
48
Airway hematomas are commonly seen in _______ (3) surgeries and can cause ________ which causes difficulty re-intubating. What are other things that this can cause? (2)
1. Neck dissections
2. Thyroid removal
3. Carotid
Supraglottic edema
1. Deviated trachea
2. Compression of trachea below level of cricoid cartilage
49
What is the Tx of Airway hematomas? What importing equipment should you have ready? (2)
1. **Decompression** of the hematoma by releasing the clips/sutures on the surgical incision --> remove SQ clot --> reintubate
Equipment:
1. Advanced emergency airway
2. Surgical airway (trach)
50
Who does the decompression of a Airway hematomas? (2)
1st: Surgeon
2nd: CRNA (if no surgeon available & need to do now)
51
What is vocal cord palsy associated with? (5)
1. Otolaryngologic sx
2. Thyroidectomy
3. Parathyroidectomy
4. Rigid Bronchoscopy
5. Overinflated ETT cuff
52
What's the difference between unilateral & bilateral vocal cord palsy?
Unilateral:
-Often asymptomatic
Bilateral:
-Can't talk
-Can't breathe on own
53
Vocal cord palsy is due to damage to the ____________ nerve, which paralyzes the _______ muscle. What does this result in? How does this affect the pt?
External branch of the superior laryngeal nerve
Cricothyroid muscle
This results in loss of tension & a wavy appearance to the vocal cords.
Weakness/huskies of the voice dt vocal cords not being able to tense up
54
Bilateral recurrent laryngeal nerve damage results in ______ (2). Why? What can this cause?
1. Aphonia
2. Paralyzed chords
This is dt the chords being in an intermediate position -- midway between abduction & adduction
Because of this the chords can close --> **airway obstruction**
55
What are thyroid sx pt at high risk for? (4)
1. Airway obstruction
2. Hemorrhage
3. **Hypocalcemia**
4. Increase risk of these things bc they go home the same day
56
In thyroid surgery patient you can see hypocalcemia _______ postop. What are the signs for this? (2) Describe them
24 - 48 hrs
1. Chvostek's sign:
- Stroke cheek --> **facial spasm**
2. Trouseau's sign:
-inflat BP cuff --> **carpal spasm**
57
When do hematoma form in thyroid sx? What are they caused by?
Immediately or within 24 hours
dt recurrent laryngeal nerve damage
58
Why is complete reversal of paralytics/muscle relaxant absolutely necessary?
Can cause residual neuromuscular blockade
59
How do we evaluate the complete reversal of muscle relaxants? (4)
1. Grip strength
2. Tongue protrusion
3. Ability to lift legs off bed
4. Able to hold head up for 5 seconds
60
T/F: once we have evaluated the reversal of paralytics, we know that our airway reflexes have returned
F
Just because we see the signs in our evaluation does not mean that our airway reflexes have returned --> still need to monitor
61
What is obstructive sleep apnea? What considerations rt anesthesia should we have?
A syndrome in which pts have a partial/complete blockage of the upper airway
1. Prone to airway obstruction --> need to be awake & following commands prior to extubation
2. Sensitive to opioids --> regional for postoperative pain
3. CPAP (ask them to bring theirs from home, if not --> call RT to bring one)
62
____________ is the obstructivesleep apnea questionnaire. What does it stand for? What is the scoring for this?
STOP-BANG
Snore
Tired
Observed stopped breathing
Pressure (high BP)
BMI (>35)
Age (>50)
Neck (>16in or 40cm)
Gender (male >)
Low = 0-2
Intermediate = 3-4
High = 5-8
63
T/F: most hospitals require you to leave the OR on O2 after GA
T
64
What are the causes of arterial hypoxemia? (2) Tx? (4)
Causes:
1. Pt on RA
2. Hypoventilation dt too much pain meds/benzos/gas
Tx:
1. Apply O2
2. Reverse opioids/benzos
3. Stimulate pt
4. Positioning -->sit pt up
65
What causes diffusion hypoxia? How does this affect the pt? (2)
Rapid diffusion of nitrous oxide into alveoli at the end of nitrous oxide anesthetic --> nitrous oxide dilute the Alveolar gas & **decrease the PaO2 & PaO2**
1. At RA --> arterial hypoxemia
2. Drop in PaCO2 --> depresses respiratory drive
66
Diffusion hypoxemia can persist for _______ after d/c of a _______ anesthetic, therefore it affects phase ______ in the PACU. How do we prevent this?
5 - 10 minutes
Nitrous oxide
Phase I
If the patient gets nitrous --> put them on O2!!!
67
What is the threshold for treatment w/ systemic HTN in the PACU? (2) What is the exception to this?
1. SBP > 180 mmHg
2. DBP > 110 mmHg
When the surgeon gives you a range to keep the pt's BP within --> may want tighter control of BP
68
What causes systemic HTN in the PACU? (7) What consideration should we have with this?
1. Emergence excitement
2. Shivering
3. Hypercapnia
4. Pain
5. Agitation
6. Bowel distention
7. Urinary retention
All Tx are different bc the causes are all different -- some can even be contra to each other
69
How do we Tx systemic HTN in the PACU? (4)
1. Tx underlying cause
**Rapid acting meds**
2. Labetalol 5 - 25mg
3. Hydralazine 5 - 10mg
4. Metoprolol 1 - 5mg
70
Drug dose: labetalol
5 - 25mg
71
Drug dose: Hydralazine
5 - 10mg
72
Drug dose: Metoprolol
1 - 5mg
72
What consideration should we have with treating OR pts w/ hydralazine?
Delayed onset
Need to be patient & not give another dose bc it will overdo it
73
Systemic hypotension is characterized by _______ (3). What do these things cause?
1. Hypovolemic shock --> decrease preload
2. Distributive shock --> decrease afterload
3. Cardiogenic shock --> intrinsic pump failure
74
Hypovolemic shock which is characterized by ________ is caused _______? (4)
Decreased preload
1. 3rd spacing
2. Inadequate intraop IV fluid replacement
3. Loss of sympathetic nervous system tone (dt neuraxial blockade)
4. Ongoing bleeding
75
Distributive shock which is characterized by ________ is caused by _________ long? (4)
Decreased afterload
1. Sepsis
2. Allergic reactions
3. Critical illness
4. Iatrogenic sympathectomy
76
In critically ill patient, small doses of medications could have an ________ effect. What other type of affect could it have?
exaggerated effect
It also could have no affect. it really depends!
77
What are the primary types of allergic reactions? (2)
1. Anaphylactic
2. Anaphylactoid
78
________ is the drug choice to Tx _________ rt an allergic reaction
Epinephrine
Hypotension
79
What is the most common drug class to have an anaphylactic reaction? What specific drug?
Neuromuscular blocking agents
Rocuronium
80
What are the top 3 substances rt incidents of periop anaphylaxis?
1. Muscle relaxants
2. Natural rubber/latex
3. Abx
81
Neuromuscular blockers are engineered with _____________.
Quaternary ammonium ions
82
The allergic reaction from Neuromuscular blockers are caused by a release in ___________ (3). How does this affect the body?
1. **Histamine** = vasodilation, erythema, edema, hypotension, GI constriction, tachycardia, pruritus
2. Leukotrienes (LTC)
3. Prostaglandins (PGD)
-- bronchial constriction, increased vascular permeability
83
Latex allergies are seen _____ groups. What are they? (3)
High-risk groups
1. Repeated exposures (such as healthcare workers)
2. Several surgical procedures (pts)
3. Spina-bifida pts
84
What are the latex-mediated reactions? (3)
1. Irritant contact dermatitis
2. Type IV cell - mediated reactions
3. Type I IgE - mediated hypersensitivity reactions
85
_____ is the most common abx allergy & _________ causes a direct histamine release.
PCN
Vancomycin
86
What are the clinical manifestations of Abx allergies? (7)
1. Pruritus
2. Flushing
3. Urticaria
4. Angioedema
5. Bronchospasm
6. Hypotension
7. Death
87
What's procedures can lead to sudden sepsis? (2) where is the treatment for this? (2)
1. Urinary tract manipulation
2. Billary tract procedures
Tx:
1. Fluid resuscitation
2. Pressure support (vasopressors)
88
Cardiogenic shock which is characterized by ________ is caused by _________ long? (4)
Intrinsic pump failure
1. Myocardial ischemia/infarction
2. Cardiac tamponade
3. Cardiac dysrhythmia
89
Cardiac tamponade is most common in ______ (2) surgeries
1. Chest
2. Abd
90
Risk stratification for non-cardiac surgery: High risk (2)
>5%
1. Aortic & other major vascular surgery
2. Peripheral artery surgery
91
Risk stratification for non-cardiac surgery: intermediate risk (5)
1 - 5%
1. Carotid endarterectomy
2. Head/neck sx
3. Intraperitoneal & intrathoracic sx
4. Orthopedic sx
5. Prostate sx
92
Risk stratification for non-cardiac surgery: low risk (5)
<1%
1. Ambulatory sx
2. Endoscopic procedures
3. Superficial procedure procedures
4. Cataract sx
5. Breast sx
93
What consideration should you have with myocardial ischemia in the PACU? (4)
1. Continuous ECG monitoring in **leads II & V5**
2. Computerized ST segment analysis
3. 12-lead EKG if you suspect anything
4. Serum troponin levels
94
What leads do you want to monitor if you suspect an MI? (2)
II
V5
95
MI tx includes avoiding decreasing ______ & increasing _______. List the risks associated with/ these. (9/6)
**O2 supply:**
1. Increased HR
2. Decrease arterial O2 content
3. Decrease hemoglobin
4. Decrease O2 saturation
5. Decrease coronary blood flow
6. Decrease coronary perfusion pressure
7. Decrease DBP
8. Increase LVEDP
9. Increased coronary vascular resistance
**O2 demand:**
1. Increase HR
2. Increase LV systolic wall stress/LV afterload
3. Increase SBP
4. Increase LV chamber size
5. Decrease LV wall thickness
6. Increase contractility
96
What are the causes of cardiac dysrhythmias?
1. Hypoxemia
2. Hypoventilation
3. Endogenous/exogenous catecholamine
4. Electrolyte abnormalities
5. Anemia
6. Fluid overload
97
The most common cardiac arrhythmia is _________. what is a characterized by? (3)
Sinus tachycardia
1. HR > 100
2. Narrow complex
3. Regular rhythm
98
What are the most common causes of sinus tachycardia in the OR? (5) What are less common causes? (4)
More common:
1. Sympathetic stimulation (including pain)
2. Hypovolemia
3. Anemia
4. Shivering
5. Agitation
Less common:
1. Bleeding
2. Shock
3. Thyroid storm
4. Pulmonary embolism (PE)
99
Atrial dysrhythmias are higher after _________ (2) surgeries. What are other risk factors for this? (4)
1. Cardiac
2. Thoracic
Risk factors:
1. Pre-existing cardiac risk factors
2. Positive fluid balance
3. Electrolyte abnormality
4. Oxygen desaturation
100
How does treatment for a fib differ for chronic afibers vs new onset? What is the medication of choice for these pts? (2)
Chronic = rate control
New onset during surgery = rhythm control & need to get them out of that rhythm
Medications:
1. BB
2. CCB
101
How do we always treat hemodynamically UNSTABLE pts in Afib 1st?
Cardioversion
102
Ventricular dysrhythmia are characterized by _______ that are _____ ms.
Wide QRS complexes
>120 ms
103
T/F: PVC are not common
F
They are common
104
True ventricular tachycardia is ______. What is this indicative of? What do we need to do?
Rare
Underlining cardiac pathology
Investigate the H's & T's
105
Bradydysrhythmias are characterized by HR ______. What increase the risk for this? (4)
<60 bpm.
1. Bowel distinction
2. IICP
3. IIOP
4. Spinal anesthesia
106
High spinal reaching _______ level can block the _______ fibers resulting in profound bradycardia. What else could happen?
T1 - T4
Cardiac accelerators
The combination of sympathectomy, bradycardia, and lack of intervascular volume --> arrest
107
Define delirium
Acute change in cognition or disturbance of consciousness that cannot be attributed to a pre-existing medical condition, substance intoxication, or medication
108
Postop cognitive dysfunction & delirium has a high incidence in _________ (2)
1. Elderly
2. Specific surgical procedures
109
T/F: You're able to tell who is suffering from postop cognitive dysfunction immediately in the PACU
F
Sometime this is masked dt anesthesia
110
What are the risk factors associated with postop cognitive dysfunction? (4)
1. Advanced age >70 yo
2. Preop cognitive impairment
3. Decrease functional status
4. Alcohol abuse
111
What are **intraop** factors associated w/ delirium? (4)
1. Blood loss (hct <30% & increased blood transfusions)
2. Hypotension
3. Nitrous oxide
4. GA vs regional
112
What are considerations we should have when managing patients with delirium in the PACU? (2)
1. Identifying high risk pts prior to sx can help guide anesthetic plan
2. Severely agitated pts may require additional PACU assistance
113
Elderly patient undergoing minor sx should be treated at an ____________ to minimize postop delirium
outpatient center
114
What should we do to a pt that has delayed awakening in the PACU? (5)
1. Evaluate vitals (ETCO2 increased too high)
2. Perform Neuro exam
3. Monitor oxygenation
4. Check labs for electrolyte abnormalities
5. Check glucose (low/high)
115
T/F: high ETCO2 can cause a patient to not wake up appropriately
T
it can be too too high
116
The #1 cause of delayed awakening in the PACU is _______. How do we treat this? (3)
Residual sedation
If residual sedation is from:
1. Opioid = Narcan 20 - 40mg increments
2. Benzos = Flumazenil 0.2mg
3. Scopolamine = Physostigmine 0.5 - 2mg IV
117
Drug dosages: Narcan
20 - 40mg increments
118
Drug dosages: Flumazenil
0.2mg
119
Drug dosages: Physostigmine
0.5 - 2mg IV
120
What are causes of delayed awakening in the PACU?
1. Hypothermia (< 33 C)
2. Hypoglycemia
3. Increase intracranial pressure
4. Residual neuromuscular blocker (residual sedation)
121
What are the recommendations for PACU d/c? (8)
1. Alert & oriented or returned to baseline
2. Minimum mandatory stay not required
3. VSS & witin acceptable limits
4. D/c after specific criteria me
5. Scoring systems may assist in documentation for d/c
6. Urination/retain clear liquids not part of routine d/c protocol
7. d/c to responsible adult who will accompany pt home
8. Provide written instructions
Principles 2 Fall 2025
flashcards
Decks in class (17)
# Cards
-
OR Communication51
-
Burns127
-
Hospital Acquired Infections & Abx132
-
Anesthesia Implications for Obesity99
-
Geriatrics37
-
Positioning82
-
SCIP24
-
ERAS96
-
PACU122
-
Acute pain138
-
OFA33
-
Immune Dysfunction109
-
General & Laproscopic Sx96
-
GU Procedures88
-
Postop NV60
-
Oncology/Chemo136
-
Common Anesthesia Meds (Pharm ppt)133
