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09/24/2012
1
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
09/24/2012
12
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
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
13
References:
• Goulette, C. (2012). Nursing’s dirty laundry. Advance for Nurses.
• Grol, R., & Grimshaw, J. (2003). From best evidence to best
practice: Effective implementation of change in patients’ care. The
Lancet, 362, 1225-1230.
• Hoover, M. (2010). News use can use about SCIP measures.
• Hudek, K. (2009). Emergence delirium: A nursing perspective.
AORN Journal, 89(3), 509-520.
• Hutton, D. (2011). Malignant hyperthermia. Plastic Surgery
Nursing, 31(1), 23-26.
• Kaplow, R. (2010). Care of postanesthesia patients. Critical Care
Nurse, 30(1), 60-62.
• Kost, M. (2006). Caring for the postanesthesia patient. 2006
Perioperative Speciality Guide. 60-67.
• Lillis, K. (2010). Preventing infection: It’s in your hands. Advance
for Nurses, p.19.
References:
• Lippincott. (2011). General patient care, PACU. Williams & Wilkins.
Loyola, S. (2010). Evidence-based teaching guidelines:
Transforming knowledge into practice for better outcomes in
healthcare. Critical Care Nurse Quarterly, 33(1), 19-32.
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