1 - Basics; Post Anesthesia Care

Front 1

What standard is this:
"all pts who have been given GA, regional, or MAC should be given appropriate postanesthesia management"

Back 1

standard I

Front 2

What standard is this:
"a pt transported to the PACU should be accompanied by a member of the anesthesia team who is knowledgeable about the pts condition"

Back 2

standard II

Front 3

which standard is:
"on arrival to PACU the pt shall be re-eval and a verbal report given..."

Back 3

standard III

Front 4

which standard is:
"the pt's condition shall be eval continually in the PACU"

Back 4

standard IV

Front 5

which standard is:
"a physician is responsible for the d/c of the pt from the PACU"

Back 5

standard V

Front 6

What is "hypoxia resulting from rapid elimination of nitrous oxide resulting in a dilution of alveolar O2 and CO2 levels"?

Back 6

diffusion hypoxia

can stil happen during xport to PACU - esp if xport on RA

Front 7

what period is characterized by a high incidence of potentially life-threatening respiratory and circulatory complications?

Back 7

recovery

Front 8

define delayed emergence

Back 8

the pt fails to regain consciousness 30-60 min after GA

Front 9

name some causes of delayed emergence

(7)

Back 9

1. residual effects of anesthesia
2. potentiation of drug effects by etoh or drug intox
3. hypothermia (<33)
4. perioperative stroke
5. hypoxemia
6. hypercarbia
7. hypoglycemia

Front 10

what is the tx for opioid od?

Back 10

nalaxone 40mcg titrate to effect
(lasts 30-45 min)

Front 11

what is the tx for benzo od?

Back 11

flumazenil 0.2mg titrate to effect
(duration 1-2 hrs)

may increase icp, induce sz, n/v, anxiety

Front 12

this is commonly due to loss of pharyngeal muscle tone in the obtunded pt causing the tongue to fall back against the post pharynx

Back 12

upper airway obstruction

Front 13

what are signs of upper airway obstruction?

Back 13

paradoxical breathing:
retraction of sternal notch
exaggerated abd. muscle activity

Front 14

Name 5 pts at high risk for upper airway obstruction.

Back 14

1. OSA
2. pts who received benzos
3. children p instrumentation of airway due to glotic edema
4. difficult airway, multiple intubation attempts
5. pts who received intraop muscle relaxants

Front 15

What is the tx for upper airway obstruction?

Back 15

1. head tilt, jaw thrust
2. PP via ambu (5-15 cm H2O)
3. NPA/OPA
4. LMA
5. Intubation
--racemic epi for subglottic edema (airway trauma)

Front 16

What does sustained head lift >5 sec reflect?

Back 16

generalized motor strength and ability to protect the airway

Front 17

Name 2 pts at higher risk for laryngospasm

Back 17

1. p deep extubation and upon awakening in the PACU
2. smokers and pts with blood or secretions in airway

Front 18

What is tx for laryngospasm?

Back 18

1. jaw thrust, CPAP 40 cm H2O 100% O2
2. Succinylcholine 0.1 to 1 mg/kg if #1 fails

Front 19

What can occur after ENT procedures, prolonged t-burg, or prone procedures?

Back 19

airway edema

-may not be visible on outside

Front 20

What are 2 types of cases with increased risk of airway hematoma?

Back 20

1. carotid endarterectomy
2. thyroidectomy

Front 21

What is tx for airway hematoma?

Back 21

1. release sutures, evac hematoma prior to reintubation
2. emergent trach by surgeon

Front 22

What is tx for airway edema?

(depends on presentation)

Back 22

1. racemic epi
2. IV steroids
3. cricothyroidotomy
4. tracheostomy

Front 23

Describe negative pressure pulmonary edema.

Back 23

1. complete airway obstruction during laryngospasm resulting in inc and sustained neg pressure
2. neg pressure increases venous return to heart and decreases CO
3. inc pulm blood volum and vasc pressures --> increased pulm capillary perm and pulmonary edema

Front 24

What is the treatment for neg pressure pulm edema?

Back 24

O2
diuretics
intubation and PPV if necessary

(pulmonary edema onset w/in 90 min of post glottic obstruction)

Front 25

Name common causes of hypoventilation.

(7)

Back 25

1. residual anesthesia
2. opioid induced
3. excessive sedation
4. hypothermia
5. inadeq. reversal
6. splinting
7. diaphragmatic disfx

Front 26

What happens with moderate resp acidosis per lecture notes?

Back 26

tachycardia
HTN
cardiac irritability

Front 27

What happens with severe resp acidosis?

Back 27

circulatory depression

Front 28

Does O2 therapy during hypoventilation prevent arterial hypoxemia?

Back 28

Si

Front 29

What is a specific drug that can be given for hypoventilation and SE?

Back 29

doxapram 60-100mg IV (.5-1mg/kg)
SE: tachycardia, hyperactivity, bronchospasm, sz

Front 30

what does decreased FRC lead to?

Back 30

intrapulmonary shunting

HPV blunted by PIA's

Front 31

Name 2 signs of late hypoxemia

Back 31

1. obtunded
2. cardiac depression

Front 32

treatment of hypoxemia

Back 32

tx underlying problem
diuretics, CT, bronchodilators.
O2 tx guided by ABG & SPO2
pulmonary toilet
intubation for severe

Front 33

Systemic hypertension usually occurs w/in 30 min of admission to PACU...name some causes

Back 33

1. incisional pain
2. bladder distention
3. pre op HTN
4. hypovent
5. hypercapnia
6. emergence excitement
7. smoking
8. kidney dz
9. gastric dilation
10. hypoxemia
11. PONV
12. neuro condition

Front 34

What are 2 indication to tx HTN?

Back 34

1. SBP or DBP >30% of baseline
2. Symptomatic (HA, angina, bleeding, etc)

Front 35

Name 3 possible causes of systemic hypotension

Back 35

1. pre-load
2. myocardial disfx
3. SVR

Front 36

Most common cause of hypotension?

Back 36

hypovolemia

tx with 300-500cc crystalloid
or 250cc colloid

Front 37

Name 3 causes of decreased afterload

Back 37

1. regional (T4 block sympathectomy)
2. anaphylactic/oid rxn
3. sepsis

Front 38

Name 8 causes of post op tachycardia

Back 38

1. pain
2. agitation
3. hypoventilation
4. hypovolemia
5. shivering
6. shock
7. MH
8. full bladder

Front 39

Name 2 tx for a fib per PP slides

Back 39

1. rate control with BB or CCB
2. cardioversion --> chemical (amiodarone)or electric

Front 40

What cardiac dysrhythmia reflects severe myocardial ischemia, systemic acidosis, or hypoxemia?

Back 40

VT or V fib

Front 41

TRUE/FALSE

Most PVC's are benign and due to excessive SNS activity, stim from central catheters, HTN, hypomag, hypokalemia.

Back 41

TRUE

Front 42

Name 9 causes for bradycardia.

Back 42

1. BB
2. opioids
3. dexmedetomidine
4. Excess PNS activity (gagging, bladder dist, etc)
5. dec SNS activity (high spinal)
6. heart block
7. hypoxemia
8. acidemia
9. myocardial ischemia

Front 43

What is the tx for shivering in the normothermic pt?

Back 43

meperidine 12.5-25 mg

Front 44

what are the values for mild, mod, severe hypothermia

Back 44

mild -- 33-35
mod -- 28-33
severe -- <28

Front 45

What is hypothermia triggered by?
(5)

Back 45

1. Cold OR
2. large wound
3. unwarmed fluids
4. high flows
5. volitile agents

Front 46

What is infrared rays emanating from all objects?

Back 46

radiation
40-50% heat loss to the ceiling, floors, walls

Front 47

What is transfer of heat from air passing by objects?

Back 47

convection
20-35% from body surface thru air current

Front 48

What is heat loss from water vaporization?

Back 48

evaporation

Front 49

What is transfer of heat from contact with objects?

Back 49

conduction

Front 50

What are the complications of post op hypothermia and shivering?

Back 50

1. increase O2 consuption 200%
2. Increase SNS activity
3. left shift of hemoglobin curve
4. decrease plt fx and clotting fx
5. vasoconstriction and hypoperfusion - may clot tissue grafts, promote hypoxia and acidemia
6. interferes with spo2 reading and arterial pressure monitoring

Front 51

How do u prevent intra-op hypothermia?

Back 51

1. warm OR
2. Use air/fluid blankets
3. humidify gas and use low flow
4. warm IVF
5. in PACU - warming blanket
meperidine, clonidine, opioids, etc

Front 52

Who are at higher risk for AMS after sevoflurane?

Back 52

children and young adults

Front 53

What are 2 metabolic abnormalities that cause AMS?

Back 53

1. Hypoglycemia - agitation
2. Hyponatremia - agitation, disorientation, nausea, visual disturbances

Front 54

What surgeries are higher risk for post op delirium?

Back 54

hip fx, bilateral knee replacement (old peeps)

worse with pre-existing dementia, parkinsons, hearing/visual impairment, sleep deprivation

Front 55

What are causes of oliguria?
(<0.5ml/kg/hr)

Back 55

1. hypovolemia
2. low CO
3. clot in catheter
4. intra-op events - severe hypotension, cross-clamp, pneumoperitoneum

Front 56

What are tx for oliguria?
(5)

Back 56

1. 300-500cc crystalloid bolus
2. HCT measurement
3. Furosemide 5mg IV
4. consider obstruction, renal art/vein occulusion, atn, surgical injury to ureters
5. nephrology consult

Front 57

What are 3 possible causes of polyurea?

Back 57

1. large intraop fluid admin
2. osmotic diuresis caused by hyperglycemia
3. DI

Front 58

Name 4 causes of bleeding abnormalities according to lecture notes.

Back 58

1. inadequate surgical hemostasis
2. coagulopathy due to hypothermia
3. massive blood xfusion - dilutional
4. inadeq. reveral of heparin

Front 59

Tx for bleeding abnormalities

Back 59

protamine
xfusion of PLT, FFP

Front 60

Name some prophylactic measures to decrease the incidence of PONV

Back 60

1. limit narcs, use toradol
2. initiate PONV prophy in preop holding for pts with documented PONV
3. use propofol for induction
4. avoid N2O, use TIVA
5. decompress stomach
6. avoid sudden movements
7. avoid hemodynamic instability and inadeq. fluid replacement

Front 61

dose of granisetron

Back 61

.35-1mg IV
at end of surgery

Front 62

dose of ondansetron

Back 62

4-8 mg at end of surgery

Front 63

What is the dose for dolasetron?

Back 63

12.5mg at end of surgery

Front 64

What is the dose for tropisetron?

Back 64

5mg at end of surgery

Front 65

what is the dose os dexamethasone?

Back 65

5-10mg before induction

Front 66

what is dose for droperidol?

Back 66

0.625mg at end of surgery

prolong QT

Front 67

what is the dose for prochlorperazine?

Back 67

5-10mg at end of surgery

Front 68

What is the dose for promethazine?

Back 68

12.5-25mg at end of surgery

Front 69

what is the dose for dimenhydrinate?

Back 69

1-2mg at end of surgery

Front 70

what is the dose for scopolamine patch?

Back 70

4hr-1 evening before surgery

Front 71

what is the dose for ephedrine for N/V

Back 71

0.5mg/hg IM at end of surgery

Front 72

What is the d/c criteria using the modified aldrete score?

Back 72

>9 d/c
8-9 safe
<7 low and dangerous