Questions and Answers
What is the primary reason for providing supplemental O2 during transport to the PACU?
What is the definition of delayed emergence?
What is the a common complication that can occur in the PACU?
What is the recommended action if a patient becomes agitated during emergence delirium?
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What is the primary factor that determines the speed of inhalation emergence?
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What is the main difference between awake and deep extubation?
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What is the primary route of elimination for inhalation anesthetics?
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What is the purpose of placing a soft bite block during awake extubation?
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What is the main advantage of using desflurane and sevoflurane in anesthesia?
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What is the purpose of preoxygenation during awake extubation?
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What is the primary consideration in patients with a history of postop agitation?
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What is the main difference between Phase I and Phase II PACU?
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What is the likely cause of restlessness and agitation in a postoperative patient?
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What is the definition of hypotension in the postoperative setting?
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What is the potential consequence of shivering in the postoperative period? (select 2)
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What is the cause of malignant hyperthermia?
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What is the primary treatment for malignant hyperthermia?
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What is the term for nausea and vomiting that occurs after discharge from the hospital?
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Which patient factor is associated with an increased risk of PONV?
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What is the definition of emergence in anesthesia?
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What factors are dependent on inhalational agent emergence?
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What is the relationship between alveolar ventilation and the speed of emergence from anesthesia?
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What factors influence the emergence of IV anesthesia agents?
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What are the phases of emergence from general anesthesia?
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What is considered a failed extubation?
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In which phase of emergence is extubation contraindicated?
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How should the patient respond to suctioning during deep extubation?
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What should you do after you have pulled the ETT in a deep extubation?
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What are the primary considerations for deep extubation?
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What is the typical patient population that experiences emergence delirium?
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What is the most common cause of hypotension in the Post Anesthesia Care Unit (PACU)?
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What is the most common cause of hypertension and tachycardia in the PACU?
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What is hypertension defined as?
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Postoperative dysrhythmias are usually transient and non-cardiac related
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What can be the initial signs of myocardial ischemia postoperatively?
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What is the most common source of airway obstruction?
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Laryngospasm is more common with deep extubation
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If laryngospasm does not resolve with PPV and airway techniques, what must you do?
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What complication is associated with laryngospasm?
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What pressures can be used when managing laryngospasm?
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What is the alternate name for negative pressure pulmonary edema?
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What is the cause of NPPE (negative pressure pulmonary edema)?
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In NPPE, what is the result of the negative pressure in the thoracic cavity?
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An elevation in pulmonary capillary hydrostatic pressure pushes fluid into the ____ . (select 2)
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Why are muscular patients at an increased risk of Negative Pressure Pulmonary Edema (NPPE)?
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What is the cause of cardiogenic pulmonary edema?
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In awake extubation procedures, when should the oropharynx be suctioned?
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During what part of the ventilation should you extubate to decrease the risk of aspiration?
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Acidic and large volumes of aspiration are associated with increased morbidity
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What is the cause of bronchospasm and how is life-threatening bronchospasm treated?
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What are risk factors for airway edema?
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What is the most common cause of hypoxemia in the postoperative period?
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What is the relationship between pain and hypoventilation?
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What is Virchow's triad of thrombosis?
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Why is marginal reversal more dangerous than complete neuromuscular blockade?
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What is the significance of the diaphragm recovering before the laryngeal muscles in a patient under anesthesia?
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What conditions can cause prolonged neuromuscular blockade?
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Which of the following drugs can cause prolonged neuromuscular blockade?
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What are the physiological effects of hypothermia?
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What is hypothermia associated with?
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What are the causes of prolonged depolarizing blockade?
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What is the primary cause of malignant hyperthermia?
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What is the treatment for serotonin syndrome?
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What are the common symptoms of serotonin syndrome?
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What is the strongest predictor of Postoperative Nausea and Vomiting (PONV)?
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What tool is used to assess the risk of postoperative nausea and vomiting (PONV)?
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What sedative is as effective as Zofran in preventing PONV?
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What is the mechanism of action of serotonin antagonists for the treatment of nausea and vomiting?
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What are the side effects of serotonin antagonists?
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How do antidopaminergics treat nausea and vomiting?
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What are examples of antidopaminergic drugs?
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What drug classes can be used to treat Postoperative Nausea and Vomiting (PONV)?
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What is rescue therapy used for in postoperative nausea and vomiting (PONV)?
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What are the ASA classifications?
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Study Notes
Complications of DL and Intubation
- Sore throat, trauma/dental damage, and SNS stimulation are common complications
- Sore throat can also occur with LMA
Emergence
- 1/3 of adverse airway events occur during emergence/recovery
- Emergence = from the time the gas is cut off and the patient is able to manage their own airway and care is transferred
- Inhalation emergence is dependent on:
- Alveolar ventilation (increased RR, increased speed of emergence)
- Agent solubility (know which agents will be the fastest off, e.g., des and sevo)
- Duration of surgery
- Speed of inhalation emergence is:
- Inversely proportional to the agent's blood solubility
- Directly proportional to alveolar ventilation
- Inhalation agents are primarily eliminated through the lungs (from brain to blood to alveoli to exhalation)
Extubation
- Awake extubation procedure:
- Preoxygenate
- Removal of throat packs, consider decompression of stomach
- Place a soft bite block to prevent negative-pressure pulmonary edema
- Position -- sniffing position or HOB elevated
- Emergence criteria met
- Suction
- PPV, deflate cuff, and pull tube
- Emergence criteria = reversal of NMB, hemodynamically stable, normothermic, analgesia, intact airway protective reflexes, and follows commands
- Deep extubation procedure (pt is comatose but spontaneously breathing with NO PROTECTIVE AIRWAY REFLEXES):
- Preoxygenate
- Removal of throat packs, consider decompression of stomach
- Place OPA
- Emergence criteria met except awake
- Suction and pt should not respond
- PPV, deflate cuff, and pull tube
- Face mask with 100% FiO2 to verify adequate Vt and no laryngospasm
PACU
- Phase I -- 1:1 nurse to patient ratio
- Phase II -- outpatient surgeries that require minimum to no monitoring
- Standard of care will remain the same
Post-Anesthesia Triage
- NORA = Non-operating room anesthetic (e.g., MRI pt given a sedative)
- General anesthesia typically cannot bypass Phase I
Bypassing PACU
- MAC cases, regional anesthesia
- PACU delay -- can go to phase II per facility policy if pt meets criteria
Transport to PACU
- Not routinely monitored for transport to PACU
- 30-50% of pts will develop transient hypoxemia on transport -- give supplemental O2 during transport
- Pt should have stable open airway, adequate ventilation and oxygenation, VSS if not, transport with monitor
Transport to ICU
- Way to provide PPV
- ETT and laryngoscope
- Medications
- Monitors
PACU Assessment
- Airway obstruction is common
- Proper handoff
Common Complications
- Postop N/V, airway obstruction, pain, cardiovascular complications
- Most detrimental are airway obstructions
Delayed Emergence
- Failure to awaken from anesthesia in 15 mins
Emergence Delirium
- More common in pediatrics and young adults
- What do you do if pt is agitated? Precedex or propofol
- Consider TIVA in pts with history of postop agitation
Postop Pain Management
- Restlessness and agitation may be initial manifestations of pain
- Opioid sparing and opioid free techniques are becoming more commonly used
- Acute pain management with fentanyl and hydromorphone
- Pts are more sensitive immediately postop so use incremental dosing
- Can do a rescue peripheral nerve block in the PACU
Hypotension and Shivering
- Hypotension = decreased BP >20% baseline, SBP <36 degrees C
- Shivering increases O2 consumption up to 400-500% and contributes to postop ventilatory and postop MI
Hyperthermia and Malignant Hyperthermia
- Hyperthermia not as frequently seen postop
- Causes = infection exacerbated by surgery, drug/transfusion reaction, MH, thyroid storm
- Malignant hyperthermia = potentially fatal reaction to volatile anesthetics/succinylcholine
- Caused by mutation in ryanodine receptor resulting in excessive calcium efflux from the SR
- Leads to uncontrolled sustained muscle contraction, muscle rigidity, myonecrosis, hypermetabolism, and severe hyperthermia
- Treatment = dantrolene or ryanodex
Serotonin Syndrome
- Caused by increased serotonin levels
- Increased risk when pts are taking serotonergic medications
- Sx = autonomic hyperactivity, agitation, dry mouth, dilated pupils, confusion
- Treatment = Supportive care and benzos
PONV
- Retching = dry heaving
- PONV = postoperative nausea and vomiting
- PDNV = post-discharge nausea and vomiting
- Patient Factors: Female, Age > 50
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Description
This quiz covers complications that can occur during anesthesia, including those related to intubation, extubation, and emergence. It also discusses sore throat and trauma/dental damage as potential risks.