09/24/2012

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Care of the PACU Patient

in the ICU Marianne E. Hess MSN, RN, CCRN

George Washington University Hospital

Objectives:

• Describe three primary concerns

in the post anesthesia patient

• Discuss two complications seen

in the post anesthesia patient

• Describe a focused assessment

for a patient recovering from

general anesthesia

Outline:

• Purpose

• Goal

• Introduction to general

anesthesia

• Primary concerns

• Complications

• Admission process

Introduction:

Indications of admission

• Patients may be admitted directly

from the OR to the ICU due to:

– Type of surgical procedure

– Intraoperative course

– Acuity of the patient

– Physician preference

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Introduction: Purpose

• The nurse must assess the patient for

the effects of anesthesia

– It’s not just the standard assessment

performed on other ICU patients. It should

be focused.

• Thus, the nurse must be familiar with:

– Standards of care for immediate post

operative patients

– Types of anesthesia

– Potential complications

“Why must we?”:

• Regulatory agencies, such as the

Joint Commission, state that the

same standard of care be provided

to patients no matter where they

receive that care

– Provision of Care Section, PC.01.02.01

Introduction: Rationale

• The patient is most vulnerable during

the initial Phase 1 post operative

(total anesthetized) state

• Aging process impacts metabolism of

anesthetics

• Adipose tissue absorbs agents

• Dangerous potential complications

Patient Goal:

• Return to baseline function

• Prevent complications

• Ensure clearance of anesthetic

medications

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Introduction to general anesthesia:

• Induction agents

• Inhalation gases

• Neuromuscular blocking agents

– “Balanced anesthesia” technique, is

more easily controlled with fewer side

effects

Induction agents:

• Cause quick loss of consciousness

• Cause rapid increase in depth of

anesthesia

• Etomidate, thiopental, propofol

Inhalation gases:

• Make a patient unconscious, amnestic,

and very little analgesia

• Reversible and dose dependent

• Desflurane, isoflurane, sevoflurane

• Side effects may include hypotension,

tachycardia, dysrhythmias,

bronchodilation, reduced response to

hypoxemia

Neuromuscular blocking agents:

• AKA Neuromuscular relaxants

– Used to facilitate intubation, retraction of

skeletal muscles, use of less inhalation

agents

– Do not provide analgesia or amnesia

– Act on neuromuscular junction

• Classified: Non-depolarizing vs. depolarizing

agent

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Neuromuscular blockers:

• Depolarizing

i.e. succinylcholine

– Cause depolarization at

receptor

– Blockade in 30-60 sec

– Half-life 4-6 min

– Can cause increase in

intracranial pressure,

intraocular pressure, &

intragastric pressure

– Adverse effects: Myalgia,

fasciculations, histamine

release, hyperkalemia,MH

• Non-depolarizing

i.e. Pancuronium,

rocuronium, vecuronium,

cisatracurium

– Prevent acetylcholine from

interacting with receptor,

preventing depolarization

– Blockade and half-life

longer

– May cause histamine

release (rocuronium)

Reversal of neuromuscular blocker:

• Can assess with use of peripheral nerve

stimulator

• Anticholinesterase agent

– Inhibit acetylcholinesterase. So, acetylcholine

levels increase and replace neuromuscular

blocker

• Neostigmine, edrophonium

– Agents give muscarinic affects such as

bradycardia, increased secretions, bronchospasm,

hyperperistalsis.

• Give antimuscarinic such as atropine glycopyrrolate

General Anesthesia:

• Loss of conscious, sensation, skeletal

muscle relaxation and loss of control of

sympathetic response to noxious

stimuli (including coughing & gagging),

amnesia, analgesia,

• Use combination of medications

Primary Concerns: Airway

maintenance

• Use of artificial airways

– Use of oral or nasal airway

• Evaluation for extubation

– Head lift for 5 seconds

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Primary Concerns: Airway

maintenance

– Laryngospasm • S&S:

– Wheezing, crackles, tachypnea, tachycardia,

decreased pulse ox, but normal filling pressures

• Related to intubation, aspiration, suctioning, histamine

release from meds (morphine, meperidine, protamine,

rocuronium)

• May result in non-cardiogenic pulmonary edema

• Can happen at any time but highest risk post extubation

• Treat with coughing, positive pressure ventilation with

bag-valve-mask, racemic epinephrine, steroids,

possible neuromuscular blocker and re-intubation

Primary concerns:

Hypoxemia/hypoventilation

• Give supplemental oxygen

• Consider reversal medications:

Neostigmine, edrophonium

– Can cause bradycardia and hypotension

so glycopyrrolate or atropine given

• Remember, inhalation agents are

eliminated through respiration

– Encourage pt. to cough & deep breath

• Splint incision

Primary concerns: Hemodynamic

stability

• Hypotension

– Inhalation agents depress sensitivity

of baroreceptors

• Treat with alpha adrenergic i.e. phenylephrine

– Due to inadequate fluid replacement or blood loss

• Treat with fluids or blood products

• Hypertension

– Due to pain, anxiety, hypothermia, hypoxia,

catecholamine release, full bladder, reversal agent

– Treat cause

Primary concerns: Hemodynamic

instability

• Heart rate

– Tachycardia (pain, anxiety, shivering,

nausea, hypovolemia, isoflurane)

– Bradycardia from reversal medications

– Dysrhythmias from electrolyte imbalances,

hypoxemia, hypothermia

• Decreased cardiac output

– Hypovolemia

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Complications of anesthesia:

Nausea & vomiting

• Incidence

– Affects 30% of patients

• 75 million pts/year

• Most common complication

– May even occur 24 hours after

procedure

Complications of anesthesia:

Nausea & vomiting

• Risk factors

– Female (premenopausal)

– Non-smoker

– Surgical manipulation of organs

– Laparoscopic surgery

– Eye or middle ear surgery

– Inhalation gases

– Opioids

– Hypovolemic patient

– History of motion sickness

Nausea & vomiting:

• Complications

–Wound dehiscence,

evisceration, increased ICP,

hypertension, aspiration,

electrolyte imbalances

Nausea & vomiting:

• Treatment

– Prophylactic treatment

– Limit head movement

– Keep NPO

– Give IV Fluids

– Antiemetics: Ondansetron, promethazine,

metoclopramide

– Aspiration prevention measures

– Head of bed elevated

– Cool environment

– Aromatherapy/accupressure

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Complications of anesthesia:

Pain management

• Inhalation agents do not

provide analgesia except for

nitrous oxide

• Non-verbal pain scoring system

• Non-pharmacologic pain relief

measures

Complications of anesthesia:

Emergence delirium

• “Dissociated state in which pt is inconsolable,

irritable, uncompromising, uncooperative,

thrashing, crying, or incoherent” (Hudek, 2009)

• Signs & symptoms:

– Usually seen within 15-30 min after surgery

– May be seen up to 24 hours after

– Restlessness, confusion, disorientation,

combative

Emergence delirium:

• Cause/risk factors:

– Preexisting delirium, pain, bladder distention,

hypoxia, age (pediatric & elderly), anxious, poor

adaptability, large blood loss, ETOH withdraw,

rapid emergence, hypoglycemia, ketamine,

inhalation agents, and opthalmological,

otorhinolaryngological, breast ,& abdominal

surgeries

• Incidence:

– All types of anesthesia

– 5.3%, (12-15% for children & elderly)

Emergence delirium:

• No identified way of preventing this

– Pre-medication with anti-anxiety med is

not beneficial

• Treatment

– Treat cause (i.e. hypoxia, bladder

distention)

– Promote patient safety (i.e. prevent self

extubation), remain calm, reorient

patient, provide quiet environment, give

benzodiazepine, limit feelings of

“confinement”

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Primary concerns:

Thermoregulation: Hypothermia

• Temp less than 36ºC (96.8ºF)

• Incidence: Especially in elderly and children

• Reduced metabolic rate can prolong effects of

anesthetics

• Complications include vasoconstriction,

increased afterload, thrombus formation,

angina, decreased platelet function,

bradycardia

• Shivering causes increased oxygen needs

– Warmers

Primary concerns:

Thermoregulation: Hyperthermia

• Think Malignant hyperthermia!

–But could be sepsis, blood

transfusion reaction

Complications of anesthesia:

Malignant hyperthermia

• Definition

–Hypermetabolic disorder of

skeletal muscles

–Pharmacogentic disorder

• Inherited

• Genetic autosomal dominance

Physiology of MH:

• Defect in cell membrane that when combined with a trigger causes:

• Release of calcium from sarcoplasmic reticulum resulting in hypermetabolic state

• High oxygen consumption ATP depletion high production of lactic acid, CO2, & heat leak of potassium from cell

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Triggering agents of MH:

• Depolarizing neuromuscular blockers

– succinylcholine

• Inhalation anesthetics

– Desflurane

– Isoflorane

– Sevoflorane

– Halothane

– Ether

Signs & symptoms of MH:

• Temperature increase (late sign)

• Muscle rigidity

• Increase CO2

• Hypoxemia

• Increased respiratory rate

• Increase heart rate

• Cardiac arrhythmia

• Acidosis

• Hyperkalemia

Treatments of MH:

• Discontinue triggering agents

• Administer Dantrolene sodium – 2.5 mg/kg

– Repeat dose every 5 minutes until symptoms subside

– Max dose is 10 mg/kg

– Continue maintenance dose with I mg/kg every

four- six hours for 24 – 48 hours after the event

• Perform cooling measures – NG & rectal lavage

– Cooled IV fluid

– Cooling blanket

– Ice packs

– Bypass

Admission Process:

• Report

– Past medical history and history of

present illness

– Preoperative status/stability

– Procedure performed

– Type of anesthesia

– Length of surgery

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Admission process: Report

• Significant events during procedure

• Such as hypotension or excessive bleeding

• Inclusion of most recent vital signs, pulse ox,

and temperature

• Medications administered

• Reversal agents

• Antibiotics

• Vasopressors

• Intake & output

• IV access & location and fluids administered

• Urine output & estimated blood loss

• Presence of dressings, wounds, & drains

Standards for assessment:

• Vital signs

– Every 15 minutes until recovered

– Includes pulse oximetery, respirations, BP,

HR; With pain & temperature every 30 min

• Aldrete Scoring System

• Grading system

• Five categories

• 0-2 score for each category

• Assess every 30 min

• Must score 8 or higher to be “recovered”

Aldrete Scoring System

• Breathing

• Circulation

• Activity

• Level of

consciousness

• Oxygen saturation

• Adequate volume & rate,

Dyspnea, or Apnea

• Blood pressure 20% , 20-

30%, or greater than 30% of

pre-admission level

• Moves all 4 extremities,

moves 2, or unable

• Awake & oriented, arousable,

or responsive to tactile

• Maintains O2 saturation

≥90% on RA, Needs O2 for

saturation ≥90, or sat ≤90%

“Discharge criteria”

• Awake, alert, oriented

• Vital signs within 15-20% of baseline

• Catheters functional

• Temperature at least 36 C and stable

• Present gag reflex

• Tolerates PO intake

• Can ambulate

• Has voided

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Perform complete physical

assessment: • Perform every 30 minutes until “recovered”

• Cardiovascular

– Hemodynamic stability

– Assess BP & HR every 15 minutes

• Respiratory

– Readiness for extubation

• Head lift for 5 seconds

– Humidified oxygen

• Pulse ox of at least 92%

– Respiratory depression

– Assess respirations every 15 min

Physical assessment:

• Gastrointestinal

– Drainage tubes

– Bowel sounds

– Nausea & vomiting (assess every 30 min)

• Renal

– Intake & output

– IVs & foley (bladder distention)

– Assess urine output every hour

Physical assessment:

• Skin integrity

– Dressings

• Antibiotics started within incision time period

• Antibiotics discontinued from end of anesthesia time

period

– Complications from positioning

– Assess on admission and every two hours, but

assess wound every 30 min

• Musculoskeletal

– Strength & sensation

• Return of function after neuromuscular blockers from

large to small muscle groups

Physical assessment:

• Neurological

– Level of consciousness & orientation

– Pupils

– Bilateral motor and sensory

• Reversal of neuromuscular blocking agents

– Dermatone level for spinal anesthesia

– Pain

• Non-verbal or verbal

• Categories from the Standards for Peri-Anesthesia Care

by ASPAN

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Operating Theater of

St. Thomas Hospital,

London England

(Hess, 1998)

Conclusion:

• And by working “together, stronger, and

bolder”, we can improve patient care.

– “Together, stronger, bolder”

• Mary Stahl, AACN’s President 2011

• But, do you dare to?

– “Dare to…”

• Kathryn Roberts, AACN’s President 2012

Questions?

Thank you for your attention

Contact information:

Marianne E. Hess MSN, RN, CCRN

Hospital Education Coordinator

George Washington University Hospital

marianne.hess@gwu-hospital.com

References:

• AACN. (2010). Clean hands help prevent infection ‘super

spreaders’. AACN Bold Voices.

• AACN. (2008). Ventilator assisted pneumonia. AACN Practice

Alerts.

• American Society of PeriAnesthesia Nurses. http://www.aspan.org

• Barone, C., Pablo, C., & Barone, G. (2004). Postanesthesia care in

the critical care unit. Critical care Nurse, 24(1), 38-45.

• CDC. (2011). Hand hygiene in healthcare setting. Retrieved April

2012 from http://www.cdc.gov/handhygiene/index.html

• Collins, A.S. (2011). Postoperative nausea and vomiting in adults:

Implications for critical care. Critical Care Nurse, 31(6), 36-45.

• Conway, B. (2009). Prevention and management of postoperative

nausea and vomiting in adults. AORN Journal, 90(3), 391-413.

09/24/2012

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References:

• Lippincott. (2011). General patient care, PACU. Williams & Wilkins.

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