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Postanesthesia Recovery
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Postanesthesia Recovery

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@SleekDramaticIrony

Questions and Answers

What is the primary reason for providing supplemental O2 during transport to the PACU?

  • To prevent emergence delirium
  • To prevent cardiovascular complications
  • To prevent transient hypoxemia (correct)
  • To prevent airway obstruction

    • What is the definition of delayed emergence?

  • Failure to awaken from anesthesia in 30 minutes
  • Failure to awaken from anesthesia in 5 minutes
  • Failure to awaken from anesthesia in 15 minutes (correct)
  • Failure to awaken from anesthesia in 60 minutes

    • What is the a common complication that can occur in the PACU?

  • Respiratory collapse
  • Cardiovascular complications
  • Airway obstruction (correct)
  • Diarrhea

    • What is the recommended action if a patient becomes agitated during emergence delirium?

    <p>If analgesia is adequate, administer a sedative (dex and propofol)</p> Signup and view all the answers

    What is the primary factor that determines the speed of inhalation emergence?

    <p>Agent solubility</p> Signup and view all the answers

    What is the main difference between awake and deep extubation?

    <p>The presence of protective airway reflexes</p> Signup and view all the answers

    What is the primary route of elimination for inhalation anesthetics?

    <p>Lungs</p> Signup and view all the answers

    What is the purpose of placing a soft bite block during awake extubation?

    <p>To prevent negative-pressure pulmonary edema</p> Signup and view all the answers

    What is the main advantage of using desflurane and sevoflurane in anesthesia?

    <p>They have a faster onset and recovery profile (low BGC)</p> Signup and view all the answers

    What is the purpose of preoxygenation during awake extubation?

    <p>To increase the patient's oxygen saturation in the FRC</p> Signup and view all the answers

    What is the primary consideration in patients with a history of postop agitation?

    <p>Considering TIVA</p> Signup and view all the answers

    What is the main difference between Phase I and Phase II PACU?

    <p>The level of monitoring required</p> Signup and view all the answers

    What is the likely cause of restlessness and agitation in a postoperative patient?

    <p>Pain</p> Signup and view all the answers

    What is the definition of hypotension in the postoperative setting?

    <p>All of the above</p> Signup and view all the answers

    What is the potential consequence of shivering in the postoperative period? (select 2)

    <p>Increased O2 consumption up to 400-500%</p> Signup and view all the answers

    What is the cause of malignant hyperthermia?

    <p>Mutation in the ryanodine receptor</p> Signup and view all the answers

    What is the primary treatment for malignant hyperthermia?

    <p>Dantrolene or ryanodex, cooling measures, hyperventilation with 100% FiO2</p> Signup and view all the answers

    What is the term for nausea and vomiting that occurs after discharge from the hospital?

    <p>PDNV</p> Signup and view all the answers

    Which patient factor is associated with an increased risk of PONV?

    <p>All of the above</p> Signup and view all the answers

    What is the definition of emergence in anesthesia?

    <p>From the time the gas is cut off and the patient is able to manage their own airway and care is transferred</p> Signup and view all the answers

    What factors are dependent on inhalational agent emergence?

    <p>Alveolar ventilation, agent solubility, and duration of surgery</p> Signup and view all the answers

    What is the relationship between alveolar ventilation and the speed of emergence from anesthesia?

    <p>Directly proportional</p> Signup and view all the answers

    What factors influence the emergence of IV anesthesia agents?

    <p>all of the above</p> Signup and view all the answers

    What are the phases of emergence from general anesthesia?

    <p>Stage 1: Surgical anesthesia/comatose but spontaneously breathing, Stage 2: Excitement/delirium, Stage 3: Sedation</p> Signup and view all the answers

    What is considered a failed extubation?

    <p>All of the above</p> Signup and view all the answers

    In which phase of emergence is extubation contraindicated?

    <p>Phase 2 - Excitement/Delirium</p> Signup and view all the answers

    How should the patient respond to suctioning during deep extubation?

    <p>No response</p> Signup and view all the answers

    What should you do after you have pulled the ETT in a deep extubation?

    <p>Mask ventilation to verify adequate VT and no laryngospasm</p> Signup and view all the answers

    What are the primary considerations for deep extubation?

    <p>Avoid coughing but increased risk of airway obstruction and hypoventilation</p> Signup and view all the answers

    What is the typical patient population that experiences emergence delirium?

    <p>Healthy pediatric patients and young adults</p> Signup and view all the answers

    What is the most common cause of hypotension in the Post Anesthesia Care Unit (PACU)?

    <p>Hypovolemia</p> Signup and view all the answers

    What is the most common cause of hypertension and tachycardia in the PACU?

    <p>Pain</p> Signup and view all the answers

    What is hypertension defined as?

    <p>Increase in BP &gt;20 mmHg over baseline</p> Signup and view all the answers

    Postoperative dysrhythmias are usually transient and non-cardiac related

    <p>True</p> Signup and view all the answers

    What can be the initial signs of myocardial ischemia postoperatively?

    <p>Hypotension and tachycardia</p> Signup and view all the answers

    What is the most common source of airway obstruction?

    <p>Tongue</p> Signup and view all the answers

    Laryngospasm is more common with deep extubation

    <p>True</p> Signup and view all the answers

    If laryngospasm does not resolve with PPV and airway techniques, what must you do?

    <p>Sedate, paralyze, and reintubate</p> Signup and view all the answers

    What complication is associated with laryngospasm?

    <p>Negative pressure pulmonary edema</p> Signup and view all the answers

    What pressures can be used when managing laryngospasm?

    <p>Up to 50-60 cmH2O</p> Signup and view all the answers

    What is the alternate name for negative pressure pulmonary edema?

    <p>Post-obstructive pulmonary edema</p> Signup and view all the answers

    What is the cause of NPPE (negative pressure pulmonary edema)?

    <p>Intrathoracic negative pressure from respiratory effort against an obstruction</p> Signup and view all the answers

    In NPPE, what is the result of the negative pressure in the thoracic cavity?

    <p>Increase in blood flow to lungs causing an elevation in pulmonary capillary hydrostatic pressure</p> Signup and view all the answers

    An elevation in pulmonary capillary hydrostatic pressure pushes fluid into the ____ . (select 2)

    <p>alveoli</p> Signup and view all the answers

    Why are muscular patients at an increased risk of Negative Pressure Pulmonary Edema (NPPE)?

    <p>Ability to produce a substantial negative inspiratory force</p> Signup and view all the answers

    What is the cause of cardiogenic pulmonary edema?

    <p>Both intravascular fluid overload and CHF</p> Signup and view all the answers

    In awake extubation procedures, when should the oropharynx be suctioned?

    <p>Prior to extubation</p> Signup and view all the answers

    During what part of the ventilation should you extubate to decrease the risk of aspiration?

    <p>At the end of inspiration</p> Signup and view all the answers

    Acidic and large volumes of aspiration are associated with increased morbidity

    <p>True</p> Signup and view all the answers

    What is the cause of bronchospasm and how is life-threatening bronchospasm treated?

    <p>Bronchospasm occurs due to increase in bronchial smooth muscle tone; epi drip</p> Signup and view all the answers

    What are risk factors for airway edema?

    <p>Prolonged prone and Trendelenburg positions</p> Signup and view all the answers

    What is the most common cause of hypoxemia in the postoperative period?

    <p>Atelectasis</p> Signup and view all the answers

    What is the relationship between pain and hypoventilation?

    <p>Pain can prevent deep breathing, leading to hypoventilation</p> Signup and view all the answers

    What is Virchow's triad of thrombosis?

    <p>Vessel wall injury, stasis of blood, and hyper-coagulopathy</p> Signup and view all the answers

    Why is marginal reversal more dangerous than complete neuromuscular blockade?

    <p>Because complete block is easier to detect and intervene</p> Signup and view all the answers

    What is the significance of the diaphragm recovering before the laryngeal muscles in a patient under anesthesia?

    <p>The patient can spontaneously breathe but cannot protect their airway.</p> Signup and view all the answers

    What conditions can cause prolonged neuromuscular blockade?

    <p>Hypermagnesemia and hypocalcemia</p> Signup and view all the answers

    Which of the following drugs can cause prolonged neuromuscular blockade?

    <p>Inhaled anesthetics, LA</p> Signup and view all the answers

    What are the physiological effects of hypothermia?

    <p>Increased epinephrine and norepinephrine, increased peripheral vascular resistance, and decreased venous capacitance</p> Signup and view all the answers

    What is hypothermia associated with?

    <p>All of the above</p> Signup and view all the answers

    What are the causes of prolonged depolarizing blockade?

    <p>All of the above</p> Signup and view all the answers

    What is the primary cause of malignant hyperthermia?

    <p>Mutation in the ryanodine receptor causing excess Ca2+ release from SR</p> Signup and view all the answers

    What is the treatment for serotonin syndrome?

    <p>Supportive care and benzodiazepines</p> Signup and view all the answers

    What are the common symptoms of serotonin syndrome?

    <p>All of the above</p> Signup and view all the answers

    What is the strongest predictor of Postoperative Nausea and Vomiting (PONV)?

    <p>Use of volatiles</p> Signup and view all the answers

    What tool is used to assess the risk of postoperative nausea and vomiting (PONV)?

    <p>Apfel score</p> Signup and view all the answers

    What sedative is as effective as Zofran in preventing PONV?

    <p>Propofol</p> Signup and view all the answers

    What is the mechanism of action of serotonin antagonists for the treatment of nausea and vomiting?

    <p>Block the binding of serotonin to 5-HT3 receptors in the gut and central nervous system, decreasing the stimulation of the vomiting center.</p> Signup and view all the answers

    What are the side effects of serotonin antagonists?

    <p>Headache and QT prolongation</p> Signup and view all the answers

    How do antidopaminergics treat nausea and vomiting?

    <p>By blocking dopamine receptors in the chemoreceptor trigger zone</p> Signup and view all the answers

    What are examples of antidopaminergic drugs?

    <p>All of the above</p> Signup and view all the answers

    What drug classes can be used to treat Postoperative Nausea and Vomiting (PONV)?

    <p>All of the above</p> Signup and view all the answers

    What is rescue therapy used for in postoperative nausea and vomiting (PONV)?

    <p>To treat vomiting rather than prevent nausea</p> Signup and view all the answers

    What are the ASA classifications?

    <p>I: A normal healthy patient</p> Signup and view all the answers

    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.

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