Lesson 9 Postop Emergence and Recovery.docx

- Complications from DL and intubation - Sore throat - Trauma/dental damage - SNS stimulation - Sore throat can also occur with LMA - 1/3 of adverse airway events occur during emergence/recovery - Extubation complications -- pt's breath hold during extubation, res...

- Complications from DL and intubation - Sore throat - Trauma/dental damage - SNS stimulation - Sore throat can also occur with LMA - 1/3 of adverse airway events occur during emergence/recovery - Extubation complications -- pt's breath hold during extubation, restricted airway access - Emergence = from the time the gas is cut off and pt 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 (des and sevo) - Inhaled anesthetics with lower solubility have quicker onset and recovery profiles - 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) - IV agent emergence dependent on redistribution, metabolism, elimination, Vd, CSHT, dose x duration - TIVA wakeup less predictable than inhalation emergence - Phase of emergence reverse of general anesthesia phases - Never extubate in phase 2 due to risk of laryngospasm - Awake extubation procedure -- will do this the majority of the time - Preoxygenate - Removal of throat packs, consider decompression of stomach - Place a soft bite block to prevent negative-pressure pulmonary edema from biting the tube - 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 - Awake or deep extubation is the decision of the CRNA - Deep extubation = pt is comatose but spontaneously breathing with NO PROTECTIVE AIRWAY REFLEXES - Deep extubation procedure - 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 - Straight to ICU - Standard of care will remain the same - Post-anesthesia triage - NORA = Non-operating room anesthetic e.g. MRI pt you gave a sedative - General anesthesia typically cannot bypass Phase I - Bypassing PACU via the fast-track - 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 = 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 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 (5HT) 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 \