Title of Presentation Arial 50pt Bold - Cleveland Clinic · pneumo, non pulmonary-MI, hypothermia,...
Transcript of Title of Presentation Arial 50pt Bold - Cleveland Clinic · pneumo, non pulmonary-MI, hypothermia,...
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Perianesthesia
Complications
Toni Zito, MSN, RN, CPAN
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Objectives
• Review special cases including:
- Airway complications
- Cardiology
- PONV
- Malignant Hyperthermia
- ABGs (Handout)
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Complications-Airway
- Obstruction
- Laryngospasm
- Bronchospasm
- Pulmonary Edema
- Pulmonary Embolism
- Hypoventilation
- Aspiration
- Pneumothorax
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Obstruction
• Upper airway-tongue, swelling,
secretions
• Reposition, suction, artificial airway,
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Laryngospasm
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Signs and Symptoms
• Partial/Complete
- Agitation
- Anxiety, panic
- Dyspnea, hypoxemia, hypercarbia
- Crowing Respirations
- Stridor
- Absent breath sounds with visible effort
- Use of abdominal or accessory muscles
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Precipitating Factors
- Excess secretions
- Vomitus
- Blood
- Airway placement
- Coughing
- Frequent suctioning
- Pungent inhalational anesthetics
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Nursing Interventions
- Reduce environmental stimuli
- Administer humidified O2
- Positive pressure ventilation with BVM with 100% O2
- Succinylcholine
- Steroids
- Lidocaine
- Reintubate
- Prevention-extubation deep or still asleep
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Bronchospasm
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Risk Factors
-Aspiration
-Tracheal/pharyngeal suctioning
-Intubation
-Histamine release
-allergic response
-COPD
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Signs and Symptoms
- Wheezing
- Shallow, noisy respirations
- Dyspnea
- Use of accessory muscles
- Tachypnea
- Decreased O2 saturation
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Nursing Interventions
- Decrease airway irritability
- Administration of bronchodilators
- Humidified O2
- If severe, consider muscle relaxants,
lidocaine, epinephrine and
hydrocortisone
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Pulmonary Edema
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Risk Factors
-Fluid Overload
-Laryngospasm
-Narcotics
-PE
-LVF, MV dysfunction
-Sepsis
-DIC
-Naloxone administration in young adults
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Signs and Symptoms
• Signs/Sx
- Tachycardia
- Dyspnea
- Tachypnea
- Confusion
- Wheezing
- Hypotension
- Pink frothy sputum
- Infiltrates on CXR
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Nursing Interventions
• Reduce the cardiac workload
• Place in upright position
• Remove and treat the causes of edema
• Anti-anxiety measures
• Maintain oxygenation
• Administer diuretics
• Maintain fluid restrictions
• I and O
• Consider afterload reduction
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Pulmonary Edema
Negative Pressure Pulmonary Edema
or Non-Cardiac Pulmonary Edema
Can be associated with an increased
inspiratory force prior to or
associated with extubation
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Pulmonary Embolus
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Risk Factors
• Virchow’s Triad
• Obesity
• CHF
• Immobility
• Malignancy
• Fracture-Pelvic,Long Bone
• Surgery
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Signs and Symptoms
• Hypoxia
• Restlessness
• Headache
• Apprehension
• Delirium
• Splinting
• Retractions
• Pleuritic Pain
• JVD
• Chest Pain
• Dysrhythmias
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Nursing Interventions
• Correct hypoxemia
• Support cardiac output
• Heparin therapy
• Bedrest
• Fluids
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Hypoventilation
Signs and Symptoms
↓ respiratory rate
↓ respiratory depth
Retention of CO2 >45 mm/Hg
Hypoxemia
Nursing Interventions
Stimulate patient to increase RR and depth
Identify and remove cause
Intubation and mechanical ventilation
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Aspiration
Causes- teeth, obesity, full stomach, trauma, ETOH
Signs/Symtoms-depend on cause
dyspnea, cyanosis, tachycardia, cough, hypoxemia
bronchospasm
Nursing Interventions- removal of FB, airway
support, proper positioning, for gastric contents-steroid
and antibiotic
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Pneumothorax
Risk Factors-PPV, Central line placement, brachial
plexus or intercostal nerve blocks
Signs/Symptoms-apprehension, cyanosis, chest pain,
diminished breath sounds on affected side, tracheal shift
toward unaffected side
Nursing Interventions-observe, CXR, O2, prepare
for chest tube insertion (pneumo >20%)
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Cardiovascular
• Cardiovascular Function
• Hypotension/Hypertension
• Cardiac Dysrhythmias
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Cardiovascular
• Preload-reflects the venous return to the
heart and is a measure of right heart
function
• RAP, CVP,PCWP
• Afterload-resistance the heart must work
against to eject blood out of the left
ventricle
• DBP or SVR
• Contractility-CO or CI (CO x BSI)
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Care of Cardiac Surgery
Patients
Potential Complications
1. Bleeding
a. Surgical causes
b. Non surgical causes
2. Cardiac Tamponade
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Care of Cardiac Surgery
Patients
Potential Complications
3. Cardiogenic Shock
low output syndrome
4. Arrythmias
pulmonary cause-ETT, pneumo,
non pulmonary-MI, hypothermia, electrolytes
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Pearls of Wisdom
*Know about blood products available for your patient
*Know risk factors for potential complications
*Be prepared for sudden changes in patient’s status
*Keep one eye on the monitor
*And the other on the patient and chest tubes
*Know your equipment
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Hypotension/Hypertension
• Blood pressure change from 20-30% of
baseline
• Common causes-volume, medications
(narcotics, anesthetics), pain, ischemia,
• Treat causes
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Cardiac Dysrythmias
• Treat Causes
• ACLS protocol
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PONV
Incidence
occurs in 1/3 of patients undergoing surgery
up to 80% incidence among patients with predetermined risk factors
Causes-Multifactorial, therapy multimodal
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Independent Risk Factors
*female
*nonsmoker
*history of PONV
*history of motion sickness
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Associated Risk Factors
- Age
- Presence of delayed gastric
emptying
- ASA status
- Anxiety
- Pain
- Preoperative Fasting
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Associated Surgical Risk
Factors
- Surgery duration
- Type of Surgery
ENT
Abdominal
Ophthalmic
-Hypovolemia
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Associated Anesthetic Risk
Factors
-Use of volatile anesthetics or nitrous
oxide
-Perioperative Opioid Administration
-Type of Approach
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Consequences
- Physiological-surgical site disruption, fatigue, dehydration, electrolyte imbalance, airway compromise with aspiration, ↑ICP, ↑intraorbital pressure
-Delay oral nutrition and drug therapy
interference with diabetic and antihypertensive drugs
-Increased costs-
delayed discharge, cost of treating, nursing time, unplanned admissions
-Patient satisfaction
PONV is among the top ten undesirable outcomes of surgery.
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Multimodal Management
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Prophylactic Treatment
- Hydration
- TIVA (Propofol and Oxygen)
- Medication
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Medications
Serotonin Receptor Antagonists (5-HT3)
Ondesetron, dolasetron, granisetron
Dopamine Receptor Antagonists (D2)
Droperidol, Prochlorperazine, Metoclopramide
Histamine Receptor Antagonists
Promethazine, Diphenhydramine
Muscarinic Receptor
Atropine, Glycopyrolate, Scopolamine patches
NK1-Substance P
Aprepitant
Dexamethasone is often used in combination with 5-HT3 or D2 blocking agent
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Rescue Treatment
- Drug used for prophylaxis should not
be used for rescue in immediate
postop period
- Select an agent with a different
receptor blocking ability
- Prochloperazine, Promethazine
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Non Pharmacologic
Interventions
Ginger
Aromatherapy (essential oils-peppermint, isopropyl alcohol)
Accupressure, accupuncture
Supplemental oxygen
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Nursing Interventions
- Know patient’s risk factors
- Environment of care-decrease
stimulation
- Ensure hydration
- Move patients slowly
- Provide adequate analgesia
- Patient education
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Thermoregulation
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Unplanned Perioperative
Hypothermia (UPH)
• Unexpected core temperature decrease
to less than 36º C as a result of surgery
or other procedure.
• May be present regardless of patients
temperature if shivering, peripheral
vasoconstriction or piloerection.
• Generalized depression of the
metabolism
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Unplanned Perioperative
Hypothermia (UPH)
Radiation-loss of energy through radiant electromagnetic waves (no direct contact-warm to
cool-limit skin exposure, warming blankets, head covering)
Convection-transfer of body heat to cooler air (fan, laminar flow)
Conduction-transfer of heat through direct contact with cooler objects (OR table, IV fluids)
Evaporation-transfer of heat when a liquid is changed to a gas (respirations,gases, exposed
viscera)
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Risk Factors
• Every patient undergoing surgery
• Age
• Female Gender
• BMI
• Procedure duration
• Body surface uncovered
• Anesthesia duration
• General or Regional Anesthesia
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Consequences
- Patient discomfort-shivering, feels cold
- Increase in serum catecholamines
- Untoward cardiac events
- Coagulopathy
- Altered drug metabolism
- Impaired wound healing/surgical site
infections
- Increased hospital costs
- Increased LOS
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Patient Management
-Monitor pre, intra and postoperatively
-Implement passive warming
-Maintain ambient room temperature
-Institute active warming for
hypothermic patients
-Consider preoperative warming
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Malignant Hyperthermia
• Biochemical chain reaction response in
susceptible individuals by anesthetics
• Leads to hypermetabolic state
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MH
- Incidence-1:100,000 surgeries/adults
1:30,000 surgeries/children
- Many undetected cases
- Males > Females
- Mean age 15
- Genetically inherited-autosomal
dominant gene
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Risk Factors
-History of anesthesia complications
-Unexplained family history of periop fever or
muscle rigidity
-Unexplained death during surgery of a
family member
-Patients with preexisting muscle disease
-Developing cola color urine postoperatively
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Triggers
Agents
- Depolarizing muscle relaxants-
• SUCCINYLCHOLINE
- ALL volatile inhalation agents
Situations
Emotional stress, strenuous exercise, trauma, heat stroke
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Malignant Hyperthermia
exposure to volatile inhalation agents or succinylcholine
↓
abnormal release of calcium from the skeletal muscle
↓
sustained muscular contraction (damage and destruction of muscle cells)
↓
hypermetabolic state ( energy utilization and heat)
↓
systemic hypoxemia
↓
acidosis
↓
K+, myoglobin
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Clinical Manifestations
• Hypercarbia and Hypoxia
• Tachycardia and Dysrhythmias
• Tachypnea
• Muscle Rigidity
• Hyperkalemia
• Temperature Elevation
• Acidosis
• Coagulopathy
• Rhabdomyolysis
• LVH
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Treatment
• Recognition
• Remove all triggering agents
• Stop procedure ASAP
• Administer 100% Oxygen
• Dantrolene
• Cooling
• Maintain Fluid and electrolyte balance
• Monitor Cardiac Status-avoid calcium channel blockers
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Dantrolene
Reconstituted with 60 ml of sterile preservative
free water
Dosage
- 2.5/mg/kg IVP rapidly up to total of 10
mg/kg (initial)
- Repeat 4 mg/kg in divided doses every 4-6
hours (IVP or orally) up to 48 hours
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Testing for MH
• Testing usually reserved for those with
family history of MH
• Most accurate and reliable test-Caffeine
Halothane contracture test
• Patient and Family teaching and
support through MHAUS
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Pain
• ASPAN’s Pain and Comfort Guidelines
• Assessment Scales
• Pharmacologic and NonPharmacologic
Approaches to Pain Management
• Patient Teaching and Education
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