Anesthesia for PACU, ICU, MODS dictated slides 29-70

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Laryngospasm :

Laryngospasm Consists of prolonged intense glottic closure in response to direct glottic or supraglottic stimulation from inhaled agents, secretions, or foreign bodies Ranges from high-pitched squeaky sounds to total absence of sound Treatment: Displace mandible and extend neck (laryngospasm notch) Strong manual positive pressure of O2 via mask and bag may forcefully open adducted cords If severe, small dose of Sux 0.15-0.30 mg/kg(10-20 mg) may be necessary Intubation last resort


Bronchospasm Differential diagnosis: Mechanical obstruction Inadequate depth of anesthesia Pulmonary aspiration Endobronchial intubation Pneumothorax Pulmonary embolus Acute bronchial asthma


Bronchospasm If bronchospasm suspected by loss of EtCO2, lack of chest excursion, desaturation, bradycardia  Place on 100% O2 Deepen the anesthetic (IA, propofol) Hold positive-pressure in attempt to break spasm Administer Beta-2 agonist Albuterol puffs/nebs Terbutaline SQ 0.25 mg; may repeat in 15-30 min; max dose 0.5 mg in 4 hours Epinephrine SQ 0.4 ml of 1:1000 solution Corticosteroids IV Consider Aminophylline MUSCLE RELAXANTS DO NOT RELAX BRONCHIAL SMOOTH MUSCLE

Negative pressure pulmonary edema (NPPE):

Negative pressure pulmonary edema (NPPE) Post extubation complication that can occur independently or after laryngospasm, aspiration, upper airway tumors, foreign bodies, bronchospasm, croup, airway trauma, strangulation, and difficult intubation Patients intubated with small ETT’s and breathing spontaneously are also at risk Insert bite block and extubate with positive pressure to attempt to avoid this complication


NPPE Must consider fluid overload, congestive heart failure, ARDS and aspiration of gastric contents Young, muscular black males more prone to this Results from negative intrapleural pressure created when patient inspires against a closed or obstructed glottis


NPPE Normal intrapleural pressures vary between -5 to –10 cm H2O; inspiratory pressure against a closed glottis can be as high as –50 to –100 cm H2O Such high pressures increase venous return into the thorax and pulmonary vasculature, increasing transcapillary hydrostatic pressure gradients and producing pulmonary edema


NPPE Onset of symptoms noted from 3-150 minutes after inciting event Symptoms: low O2 sat, bilateral rales, pink, frothy sputum Treatment: O2 therapy, MSO4, Lasix May require reintubation with CPAP and PEEP depending on severity Usually resolves within 12-24 hours

Prolonged intubation:

Prolonged intubation Delayed emergence from general anesthesia Inadequate reversal of neuromuscular block Inadequate gas exchange Potential for airway obstruction Full stomach precautions Hemodynamic instability Hypothermia

Complications of prolonged intubation:

Complications of prolonged intubation Or..too large a tube for brief periods Edema Cuff pressure (vocal cord paralysis) Tracheal erosion, tracheomalacia or stenosis, vocal cord damage or granuloma Prevention Choose proper size tube Securing airway so there is little movement High volume / low pressure tubes?

Complications of intubation:

Complications of intubation Following extubation Airway trauma Edema and stenosis (glottic, subglottic, or tracheal) Hoarseness (vocal cord granuloma or paralysis) Laryngeal malfunction and aspiration Physiological reflexes Laryngospasm

Extubation :

Extubation Can be performed while the patient is deeply anesthetized or fully awake Deep extubation performed for cases in which the surgery could be harmed if the patient coughs and bucks Ventral hernia repairs, plastic surgery, rises in intraocular/intracranial pressures detrimental, etc Also good for asthmatics, RAD Some studies show less laryngotracheal damage

Extubation :

Extubation Deep extubation Must reverse all muscle relaxants and patient is breathing spontaneously with an acceptable respiratory rate and depth Difficult mask ventilation, intubation, risk of aspiration, or surgery that produces airway edema are contraindications to this technique

Extubation :

Extubation Awake extubation is most commonly utilized Extubation criteria (most sensitive) Train of four 4/4 on nerve stimulator with sustained tetanus Sustained head lift > 5 seconds Sustained leg or arm lift > 5 seconds Tongue protrusion NIF > -20-25 cm H2O (need to always read how questions with NIF are written!!) Ability to hand grasp and follow commands

Guidelines for extubation in PACU:

Guidelines for extubation in PACU If patient breathing spontaneously, attach T-piece and transport to PACU Must met extubation criteria plus: RR must be < 20-30 bpm with a tidal volume of at least 3-5 ml/kg Deflate cuff and assess for leak if edema concern

Renal complications:

Renal complications Oliguria Polyuria

Acid-Base Disturbances:

Acid-Base Disturbances Respiratory acidosis Commonly encountered post-op d/t hypoventilation Metabolic acidosis Diabetics, renal disease, increased lactate states Use of large amounts of NS  hyperchloremic metabolic acidosis Respiratory alkalosis Can be encountered d/t hyperventilation from pain/anxiety; also central CNS states (sepsis, CVA) Metabolic alkalosis Rare post-op unless excessive vomiting, dehydration

Electrolyte disturbances:

Electrolyte disturbances Hyperglycemia  d/t stress response Moderate hyperglycemia (150-250 mg/dL) little effect Hypoglycemia  rare postop; tx with D50 Hyponatremia can see after TURP, hysteroscopy (sodium-free irrigating solutions used) Hypokalemia only treat if dysrhythmias occur/persist Hyperkalemia d/t acidosis, renal failure, MH Hypocalcemia d/t post-op parathyroid excision, alkalosis; rarely blood products

Neurologic complications:

Neurologic complications Delayed awakening Anesthetic effects, decreased cerebral perfusion, metabolic causes Thromboembolic/hemorrhagic event Emergence delirium Peripheral neurologic injury (positioning)

Failure to Regain Consciousness:

Failure to Regain Consciousness Preoperative intoxication Residual anesthetics: IV or inhaled Profound neuromuscular block Profound hypothermia Electrolyte abnormalities Thromboembolic cerebrovascular accident Seizure

Emergence delirium :

Emergence delirium Multiple causes: drug combination, impaired cerebral O2 supply, metabolic abnormalities, infection/fever, environment-sensory deprivation Patient history Hypoxia Methadone

Body temperature changes:

Body temperature changes Hypothermia Hyperthermia

Hypothermia (<96*F) and Shivering:

Hypothermia (<96*F) and Shivering Significant delay in PACU stay (40-90 minutes at minimum) Increased O2 consumption and CO2 production by 200% Planning and Prevention Use the tools available Start in the OR!! Forced-air warming blankets Demerol 12.5-25 mg IV


Fever Causes: Infections Drug / blood reactions Tissue damage Neoplastic disorders Metabolic disorders Thyroid storm Adrenal crisis Pheochromocytoma MH Neuroleptic malignant syndrome Acute porphyria

Nausea and Vomiting:

Nausea and Vomiting Most common complication in the PACU DDX: Hypoxia Hypotension Pain Anxiety Infection Chemotherapy Gastrointestinal obstruction Narcotics/ volatile anesthetics/ etomidate Movement Vagal response Pregnancy Increased ICP TX: IV fluids Medications (Zofran/ Phenergan/ Promethazine) Propofol

Nausea and vomiting:

Nausea and vomiting Prophylactic treatment controversial Reglan Zofran and other serotonin antagonists Decadron Droperidol Promethazine Prochlorperazine

Incidence of PONV/PDNV:

Incidence of PONV/PDNV

Anatomy of Emetic Center:

Anatomy of Emetic Center The anatomical location of the area postrema and the region of the vomiting center Vomiting center Area postrema The CTZ is located within the area postrema Nucleus of the solitary tract IVth ventricle

Pathophysiology of Emesis:

Chemoreceptor trigger zone Emetic center Area postrema Parvicellular reticular formation Receptor site Agonist Antagonist Nitrogen mustard Cisplatin Digoxin glycoside Opioid analgesics Vestibular portion of VIIIth nerve GI tract distension Higher centers (vision, taste) Pharynx Mediastinum Vagus 5-HT 3 Promethazine Atropine Droperidol antagonist N 2 O 5-HT 3 Histamine Muscarinic Dopamine (D 2 ) Pathophysiology of Emesis ?

Etiology of PONV:

Etiology of PONV Patient-specific factors Surgery-related factors Anesthetic-related factors Postoperative factors

Etiology of PONV: Patient-Specific Factors:

Etiology of PONV: Patient-Specific Factors

Etiology of PONV: Surgery-Related Factors:

Type of Surgery Incidence of PONV (%) Gynecologic surgery Gynecologic laparotomy Dilatation and curettage of the uterus 65% 40% to 77% 12% to 33% Hernia repair/orchiopexy 54% to 58% Otolaryngologic surgery Middle ear Adentonsillectomy 53% 38% to 48% 36% to 76% Ophthalmologic surgery Strabismus repair Cataract 38% 76% 14.3% Dental extractions 16% Plastic/reconstructive procedures Breast procedures Skin and other 14% 37% to 59% 17% Etiology of PONV: Surgery-Related Factors

Etiology of PONV: Anesthesia-Related Factors:

Etiology of PONV: Anesthesia-Related Factors Type of premedication Benzodiazepines decrease PONV Opioid analgesics stimulate the CTZ NSAIDs help decrease opioid use Type of anesthesia General (11x) > major regional > peripheral regional Inhalational agents (Iso>Sevo>Des) > propofol-based Duration of anesthetic exposure 30-minute increase in surgery increases the incidence of PONV by approximately 60% Experience of anesthesia provider Related inversely to the experience of the anesthetist

Etiology of PONV: Postoperative Factors:

Etiology of PONV: Postoperative Factors Uncontrolled pain, especially visceral/ pelvic pain Opioid administration Dehydration  adequate IV fluid hydration can decrease PONV Early ambulation/patient handling Early oral intake Increases PONV after conventional surgery Decreases PONV after laparoscopic surgery

Consequences of PONV:

Consequences of PONV Patient discomfort (mild to severe) Decreased patient satisfaction I ncreased cost Personnel, supplies, drugs Unplanned admissions Wound dehiscence/bleeding Aspiration pneumonitis Dehydration and electrolyte imbalance Decreased ability of patient to care for him/herself

Cost Components in PONV Episodes:

Cost Components in PONV Episodes Cost components for an episode of postoperative emesis (percentage of total median management cost per patient) *Per item of basin, glove, paper, linen, and gown. Personnel 84% Materials* 0.2% Hospital Admission 10% PACU Delay 4% Antiemetic Cost 2% MD/CRNA 5% PACU nurses 79%

Anesthesia Outcomes: Patient Perspectives:

* Patients were asked to distribute $100 among 10 outcomes, with proportionally more money being allocated to the more undesirable outcomes (eg, patients assigned $18.05 of $100 to avoid vomiting). Anesthesia Outcomes: Patient Perspectives Patients’ ranking and relative value of anesthesia outcomes Most undesirable Least undesirable Outcome Rank Relative Value/$100* Vomiting 2.56 $18.05 Gagging on tracheal tube 2.97 $17.86 Pain 3.46 $16.96 Nausea 4.02 $11.82 Recall without pain 4.85 $13.82 Residual weakness 5.34 $7.99 Shivering 5.36 $7.60 Sore throat 8.02 $3.04 Somnolence 8.28 $2.69

Prophylactic Antiemetic Intervention Assessment Scale (Gan):

3 or More Points Prophylactic Antiemetic is Indicated 1 Point Each • Preadolescent • Laparoscopic cholecystectomy • Female • Intraoperative or postoperative opioid • Anxiety • Duration of anesthesia >60 min 2 Points Each • Facelift surgery • Strabismus or middle ear surgery • Neurosurgery • Obesity 3 Points Each • History of PONV • History of motion sickness • Gynecologic laparoscopy • Breast reconstruction Prophylactic Antiemetic Intervention Assessment Scale (Gan)

Agents Overview:

Agents Overview Drug Class Route Onset Doses in 24 h Duration Side Effects Ondansetron 5-HT 3 -receptor antagonist IV IM PO/ODT 10 min 41 min – 1 24 h HA, light-headedness abdominal pain constipation Dolasetron 5-HT 3 -receptor antagonist IV PO “rapid” 1 h 1 24 h HA, hypotension, dizziness Promethazine Phenothiazine IV IM/PO/PR 5 min 20 min 4–6 4–6 h Dry mouth, blurred vision Prochlorperazine Phenothiazine IV/IM PO/PR – 2–4 – EPS, drowsiness, dizziness Metoclopramide Substituted benzamide IV IM PO 1–3 min 10–15 min 30–60 min 4 1–2 h EPS, drowsiness, lassitude Transdermal scopolamine Anticholinergic Patch 4–24 h 1 Up to 24 h post surgery Dry mouth, drowsiness Zofran ® , Anzemet ® , Phenergan ® , Compazine ® , Reglan ® , and Transderm Scop ® prescribing information. HA = headache; EPS = extrapyramidal symptoms.

Pain management:

Pain management Opioids Fentanyl MSO4 Demerol Dilaudid Nsaids Ketorolac Cox 2 PCA/PCEA


Awareness Primary concern of patients Incidence difficult to document Awareness under general anesthesia ~ 0.2-0.4% Certain surgical settings most common Major trauma (up to 43%) Cardiac surgery (up to 1.5%) Obstetric surgery (up to 0.4%) Often due to errors in drug labeling and administration More likely in women and when relying on opioids and muscle relaxants without volatile anesthetics

Awareness: what to do to prevent:

Awareness: what to do to prevent Discuss in preop evaluation and informed consent what you will be doing to prevent awareness Remind patients that they may hear things if not under general anesthesia  this is NOT awareness BIS may be considered if utilized at your institution Benzos Volatile anesthetics should be at concentration consistent with amnesia 0.5-0.6 MAC when combined with opioids and N2O 0.8-1.0 MAC if used alone

Awareness: what to do if there is evidence:

Awareness: what to do if there is evidence Discuss with patient post-op Obtain detailed account of experience Be very sympathetic Answer questions Refer to psychological counseling Initiate adverse outcomes protocol if institution has one Should be documented and referred to QI/Risk management if occurs

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