Anesthesia for PACU, ICU MODS dictated slides 1-28

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POSTOPERATIVE PHYSICAL ASSESSMENT: ANESTHETIC CONSIDERATIONS IN THE PACU AND ICU and MODS:

POSTOPERATIVE PHYSICAL ASSESSMENT: ANESTHETIC CONSIDERATIONS IN THE PACU AND ICU and MODS Maribeth Massie, CRNA, MS, PhD(c) University of New England, MSNA Program

History of the PACU:

History of the PACU PACU has only been common for the past 50 years. 1920’s and 30’s: several PACU’s opened in the US and abroad It was not until after WW II that the number of PACU’s increased significantly; this was do to the shortage of nurses in the US In 1947 a study was released which showed that over an 11 year period, nearly half of the deaths that occurred during the first 24 hours after surgery were preventable 1949: having a PACU was considered a standard of care

PACU/ICU Location:

PACU/ICU Location Should be located close to the operating suite. Immediate access to x-ray, blood bank, blood gas and clinical labs Should have 1.5 PACU beds per operating room used. An open ward is optimal for patient observation with at least one isolation room Central nursing station Piped in oxygen, air, and vacuum for suction Requires good ventilation, because the exposure to waste anesthetic gases may be hazardous National Institute of Occupational Safety (NIOSH) has established recommended exposure limits of 25 ppm for nitrous and 2 ppm for volatile anesthetics

General considerations:

General considerations Most anesthetic recoveries are uneventful but complications do arise and can be sudden and life threatening Proximity to OR All emergency equipment available

Transport to the PACU/ICU:

Transport to the PACU/ICU CRNA at head of bed, close to patient’s airway HOB elevated ~ 30* or patient in lateral position to maximize airway patency O2 by FM or NC to counter hypoventilation and maximize oxygenation Monitor, especially if remains intubated to ICU or labile; bring emergency bag of drugs and intubating equipment Continually assess level of consciousness!

Level of Postoperative Care:

Level of Postoperative Care Choosing a post-anesthesia setting based on each patient’s need can reduce cost, enhance satisfaction, and optimize scarce PACU resources Fast tracking (Phase II) Local infiltration Minor blocks with sedation Major plexus anesthesia Use of short-acting anesthetics Biggest issues are with control of post-op pain and PONV

Report to PACU/ICU:

Report to PACU/ICU Attach to pulse ox first then rest of monitors Make sure O2 attached properly Report includes: Patient name, age, surgical procedure, diagnosis, PMH/PSH, medications, allergies, and preop vital signs Location and size of IV’s, premed, antibiotics, anesthetic drugs, additional meds Considerations specific to procedure Anesthetic course (fluids, EBL, blood products, problems, such as difficult intubation, etc)

Discharge From the PACU:

Discharge From the PACU Aldrete Score: Simple sum of numerical values assigned to activity, respiration, circulation, consciousness, and oxygen saturation A score of 9 out of 10 shows readiness for discharge. Postanesthesia Discharge Scoring System (PADSS): Modification of the Aldrete score which also includes an assessment of pain, N/V, and surgical bleeding, in addition to vital signs and activity Also, a score of 9 or 10 shows readiness for discharge

Aldrete Score:

Aldrete Score Activity Respiration Circulation (mmHg) Consciousness Color 2 : Moves all extremities voluntarily/ on command 2: Breaths deeply and coughs freely. 2: BP 20 % of preanesthetic level (normal) 2: Fully awake/alert, oriented 2: Pink  Spo2 > 92% on room air 1: Moves 2 extremities 1: Dyspneic, shallow or limited breathing 1: BP 20-50 % of preanesthetic level (normal) 1: Arousable on calling/but drifts back to sleep 1: Pale or dusky  Spo2 >90% on oxygen 0: No movement 0: Apneic or obstruction 0: BP >50 % of preanesthetic level (normal) 0: Not responding 0: Cyanotic  Spo2 <90% with oxygen

Postanesthesia Discharge Scoring System:

Postanesthesia Discharge Scoring System Vital Signs (BP and Pulse) Activity Nausea and Vomiting Pain Surgical Bleeding 2: Within 20% of preoperative baseline 2: Steady gait, no dizziness 2: Minimal: treat with PO meds 2: Acceptable control per the patient; controlled with PO meds 2: Minimal: no dressing changes required 1: 20-40% of preoperative baseline 1: Requires assistance 1: Moderate: treat with IV medications 1: Not acceptable to the patient; not controlled with PO medications 1: Moderate: up to 2 dressing changes 0: >40% of preoperative baseline 0: Unable to ambulate 0: Continues after repeated treatment 0: Severe: 3 or more dressing changes

Complications in the PACU/ICU:

Complications in the PACU/ICU Occur in ~ 7% of admissions Hemodynamic complications most frequent Hypotension (4%)  hypovolemia most common cause Inadequate venous return True hypovolemia: ongoing hemorrhage, inadequate fluid replacement, osmotic polyuria, and fluid sequestration

Hypotension:

Hypotension True hypovolemia cont’d S/s: tachycardia, hypotension, tachypnea, decreased skin turgor, oliguria, thirst Tx: fluid challenge (250-1000 ml) Persistent hypotension requires further exploration (foley catheter, invasive monitoring, reop)

Hypotension:

Hypotension Relative hypovolemia Occurs when venous return to heart is decreased by mechanical forces Can be caused by PEEP, PPV, pneumothorax, and tamponade S/S: same as true hypovolemia plus ventricular dysfunction/dysrhythmias, increased CVP, and decreased heart and breath sounds Tx: Volume; remove or correct cause (reduce airway pressure, slight t-berg)

Hypotension:

Hypotension Decreased vascular tone Acute vasodilation: general and neuroaxial anesthesia, anaphylaxis, transfusion reaction, adrenal insufficiency, sepsis After administration of certain medications and accentuated by rewarming in PACU Tx: alpha receptor agonists (Phenylephrine); treat cause Ephedrine not as desirable in certain patients d/t increased heart rate and contractility

Hypotension:

Hypotension Decreased inotropy Caused by MI, dysrhythmias, CHF, negative inotropic drugs (anesthetics, adrenergic blockers, calcium cannel blockers, antidysrhythmics), sepsis, hypothyroidism, MH S/S: dyspnea, diaphoresis, cyanosis, JVD, oliguria, rales, wheezes, S3 gallop Diagnosis: EKG, Chest X-ray, labs Tx: Inotropic agents (Dopamine, dobutamine, epinephrine, norepinephrine, amrinone) Afterload reduction agents: nitrates, calcium channel blockers, ACE inhibitors Diuresis

Hypertension:

Hypertension Commonly observed in patients with preexisting h/o hypertension, especially if preop meds were not taken Moderate amount is acceptable Excessive can cause increased bleeding, third space losses, suture line rupture Other etiologies include pain, bladder distension, fluid overload, hypoxemia, increased ICP, and from medications Tx: Beta blockers: labetolol 5- 10 mg IV; metoprolol 2.5- 5 mg IV; Esmolol 10 – 100 mg IV Pure vasodilator: Hydralazine 5- 20 mg IV Calcium channel blockers: verapamil 2.5 –5 mg IV, Diltiazem 20 mg IV

Hypertension:

Hypertension Nitrates: NTG 25 mcg/min IV; Nipride 0.5 mcg/kg/min IV Alpha-adrenergic blockers: Pentolamine 2.5-5 mg IV Diuretics Clonidine (transdermal or rectal) Dexmedetomidine

Dysrhythmias:

Dysrhythmias Caused by increased sympathetic outflow, hypoxemia, hypercarbia, electrolyte and acid-base imbalances, MI, increased ICP, drug toxicity, and MH PAC’s and unifocal PVC’s usually do not require treatment Administer O2 if dysrhythmia worsens

Sinus tachycardia:

Sinus tachycardia Result of pain, agitation, hypovolemia, fever, hypoxemia, chf or pulmonary embolism Always assess for myocardial ischemia

Paroxysmal supraventricular tachycardias:

Paroxysmal supraventricular tachycardias Include PAT, multifocal AT, Afib, and Aflutter Risk of post-op tachycardias 6%; Afib 2x as common as SVT Atrial flutter uncommon as post-op dysrhythmia Treat with synchronized cardioversion if unstable Meds: Adenosine, verapamil, diltiazem, esmolol, propranolol, procainamide

Sinus bradycardia:

Sinus bradycardia May result from high neuroaxial block, opioids, vagal stimulation, beta blockade, increased ICP, anticholinestarase dose Tx: Atropine or glycopyrolate; may need to progress to epinephrine, isuprel or cardiac pacing

Ventricular dysrhythmias:

Ventricular dysrhythmias Stable: due to hypoxemia, MI, acidosis, hypokalemia, hypomagnesemia Tx: Lidocaine, procainamide; treat problem Unstable: ACLS protocol

Myocardial ischemia/infarction:

Myocardial ischemia/infarction T wave changes associated with MI, electrolyte changes, hypothermia, surgical manipulation of mediastinum, incorrect lead placement ST segment elevation or depression more specific for MI Associated with hypoxemia, anemia, tachycardia, hypotension, hypertension Tx: Oxygen, ASA, NTG, MSO4, correct the cause 12 lead EKG Cardiology Consult

Respiratory complications:

Respiratory complications Due to hypoxemia, hypoventilation, and upper airway obstruction Hypoxemia S/S: dyspnea, tachycardia, cyanosis, altered LOC, agitation, obtundation, hypertension, dysrhythmias Atelectasis Hypoventilation Diffusion hypoxia Upper airway obstruction Bronchospasm Aspiration Pulmonary edema Pneumothorax Pulmonary embolism

Hypoventilation:

Hypoventilation Results in hypoxemia, CO2 narcosis, apnea Decreased ventilatory drive Pulmonary and respiratory muscle insufficiency Inadequate reversal Upper airway obstruction Inadequate analgesia Bronchospasm Pneumothorax

Upper airway obstruction:

Upper airway obstruction Incomplete recovery Laryngospasm Airway edema Wound hematoma Vocal cord paralysis

Upper airway obstruction:

Upper airway obstruction Total obstruction Lack of any air movement or breath sounds Chest retraction and diaphragmatic tugging are NOT signs of effective air movement MUST feel air with hand or ear over mouth  precordial stethoscope Partial obstruction Diminished tidal exchange associated with upper chest retraction and either snoring or inspiratory stridor

Treatment of upper airway obstruction:

Treatment of upper airway obstruction Soft tissue obstruction most common cause of upper airway obstruction Caused by relaxation of tongue and jaw Can also be caused by foreign body, dentures, tumors, infective process To relieve, place forefinger and second finger behind angle of mandible and exert forward pressure Can also extend neck to align airway axis

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