PACU & Complications (Exam II) Flashcards by Krista Flores

What is Standard 1 for postanesthesia care?

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

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What is Standard 3 for postanesthesia care?

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

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What is Standard 4 for postanesthesia care?

The patient shall be evaluated continually in the PACU.

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What is Standard 5 for postanesthesia care?

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

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

Phase 1

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

Phase 1

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

Neuromuscular function

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What is Standard 2 for postanesthesia care?

A patient being transported to PACU has to be monitored and taken by qualified anesthesia personnel.

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How often must vital signs be assessed and recorded during the 1st phase of recovery?

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

Target vitals to 20% of baseline.

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

Standard Aldrete Score
Modified Aldrete Score
PACU Discharge Score

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Describe the Standard Aldrete Score.

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Describe the Modified Aldrete Score.

Modified Aldrete Score

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Describe the Postanesthesia Discharge Score.

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

30 - 60 min

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

Airway and ventilation status
Pain level
PONV
Fluid balance
Wound integrity

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

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

Loss of pharyngeal muscle tone
Paradoxical breathing

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What is the treatment of upper airway obstruction?

Jaw thrust
CPAP
Oral/Nasal airway

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What are laryngospasms?

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

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What are the three most common causes of laryngospasms?

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

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What is negative pressure pulmonary edema?

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

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

Laryngospasm

Occurs in 12% of laryngospasm cases.

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What is the physiology behind laryngospasm?

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

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What would laryngospasms present like upon inspection?

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

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

**Do not squeeze bag during laryngospasm**.

How should a BVM be utilized in laryngospasm emergency?

Apply facemask with tight seal and 100% FiO₂ and closed APL valve. ***Do NOT squeeze the bag***.

What is the first step in treatment of laryngospasm?

Call for help

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

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

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

Pressure point behind of the lobule of the pinna of each ear that can help relieve laryngospasm.

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

- Tachycardia - Fast desaturation

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

Atropine, Propofol, Succinylcholine, reintubate.

What initial dose of Succinylcholine is typically used for laryngospasm?

1/10 of normal dose

What neuromuscular blocking drug can cause bradycardia in pediatric patients.

Succinylcholine

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

Facial and scleral edema

What factors can precipitate airway edema?

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

What should be done prior to extubation with expected pulmonary edema?

- Suction Oropharynx - ETT cuff leak test

How is an ETT cuff leak test done?

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.

When are airway hematomas most often seen?

- Neck dissections - Thyroid removal - Carotid surgeries

A rapidly expanding hematoma may precipitate ____________ edema.

supraglottic

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

cricoid cartilage

What is the treatment for airway hematoma post extubation?

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

What surgeries and procedures is vocal cord palsy associated with?

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

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

asymptomatic

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

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

What does bilateral Recurrent Laryngeal Nerve damage result in?

Aphonia & paralyzed vocal cords

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

Intermediate position (not adducted or abducted).

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

Airway obstruction during inspiration

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

24 - 48 hours postop

What is Chvostek's sign?

Facial spasm

What is Trousseau's sign?

Carpal spasm w/ BP cuff

What are some ways to assess for residual neuromuscular blockade?

- Grip strength - Tongue protrusion - Ability to lift legs - Able to hold head up for 5 seconds

What medication class are OSA patients sensitive to?

Opioids

What is the STOP-BANG assessment?

**S**nore **T**ired **O**bserved **P**ressure **B**MI > 35 **A**ge > 50 **N**eck circumference > 16 in **G**ender (male)

What score on the STOP-BANG assessment is indicative of a low risk for OSA?

0 - 2

What score on the STOP-BANG assessment is indicative of a intermediate risk for OSA?

3 - 4

What score on the STOP-BANG assessment is indicative of a high risk for OSA?

5 - 8

What is the full STOP-BANG questionnaire?

What are common causes of arterial hypoxemia in a PACU patient?

- Room air - Hypoventilation

What are common treatments for arterial hypoxemia in the PACU patient?

- O₂ - Opioid/Benzo reversal - Stimulate patient

What is Diffusion Hypoxia?

Rapid diffusion of N₂O into alveoli at end of anesthetic. Dilutes PaO₂ and PaCO₂ → hypoxemia w/ ↓ respiratory drive.

How long can diffusion hypoxia persist after discontinuation of N₂O anesthetic?

5-10 min

What are the standard treatment thresholds for hypertension in the PACU?

SBP > 180 DBP > 110

What medications (and doses) are typically used for treatment of systemic HTN in the PACU?

Labetalol (5 - 25mg) Hydralazine (5 - 10mg) Metoprolol (1 - 5mg)

Hypotension that is due to decreased preload is __________.

Hypovolemic shock

Hypotension that is due to decreased afterload is __________.

Distributive shock

Hypotension that is due to intrinsic pump failure is __________.

Cardiogenic shock

What are four common causes of decreased preload?

- Third spacing - Inadequate fluid replacement - Neuraxial blockade → SNS tone loss - Bleeding

What are four common causes of decreased afterload?

- Sepsis - Anaphylaxis - Critical illness - Iatrogenic sympathectomy

What are the two primary types of allergic reactions?

Anaphylactic & Anaphylactoid

What is the drug of choice for hypotension in an allergic reaction?

Epinephrine

What are the most common drug classes to cause anaphylactic reactions?

What inflammatory mediators can cause bronchial constriction and increased vascular permeability?

Leukotrienes and Prostaglandins

__________ drugs are associated with quaternary ammonium ions.

Neuromuscular blocking

What patient populations are at high risk for latex allergy?

- Repeated exposures (HCW's) - Spina Bifida patients

What are the three latex-mediated reactions?

- Irritant contact dermatitis - Type IV cell-mediated reactions - Type I IgE-mediated hypersensitivity reactions

What antibiotic causes a direct histamine release?

Vancomycin

What is the most common ABX allergy?

Penicillin

What two surgical procedures mentioned in lecture can lead to sudden sepsis?

Procedures involving urinary tract & biliary tract manipulation

What are the three most common causes of intrinsic pump failure?

- Myocardial ischemia/infarction - Tamponade - Dysrhythmias

What is the risk stratification guideline for non-cardiac surgery?

What are factors that decrease myocardial O₂ supply?

What are factors that increase myocardial O₂ supply?

What are the most common causes of sinus tachycardia?

- SNS stimulation - ↓ volume - Anemia - Shivering - Agitation

Risk for atrial dysrhythmias is greatest after what types of surgeries?

Cardiac and Thoracic

What are risk factors for atrial dysthrythmias?

- Pre-existing cardiac conditions - Hypervolemia - Electrolyte abnormalities - O₂ desaturation

Patients that are hemodynamically unstable due to atrial dysrhythmias require _________.

cardioversion

What medications tend to work well for atrial fibrillation?

- β blockers - CCBs

Greater than ____ ms QRS complex is considered wide.

120 ms

What should be investigated with true ventricular tachycardia?

H's & T's

What procedures are associated with bradydysrhythmias?

- Bowel Distention from GI stuff - ↑ ICP (Trendelenburg, etc.) - ↑ Intraocular (eye sx's) - Spinal Anesthesia

High spinals reaching the _______ level can block the cardioaccelerator fibers.

T1 - T4

What risk factors for Postoperative Cognitive Dysfunction (POCD) were discussed in lecture?

- > 70 years old - Pre-operative cognitive impairment - ↓ Functional status - EtOH abuse

What intra-operative factors are associated with POCD?

- Surgical blood loss (HCT < 30%, PRBC infusions) - ↓ BP - NO administration - GETA

What is the #1 cause of delayed awakening?

Residual sedation from anesthetic

For delayed awakening secondary to opioids treat with ________ mcg of naloxone.

20 - 40 mcg

For delayed awakening secondary to benzodiazepines treat with ________ mg of flumazenil.

0.2mg

For delayed awakening secondary to scopolamine treat with ________ mg of ___________.

0.5 - 2mg IV Physostigmine.

What (besides residual sedation) are some common reasons for delayed awakening from anesthesia?

- Hypothermia < 33°C - ↓BG - ↑ICP - Residual NMBD's

What are some basic recommendations for discharge from PACU?

What is/are the criteria for Determination of Discharge from PACU Score?

PACU & Complications (Exam II) Flashcards

(100 cards)