Information Often Given to the Nurse at the Time of Admission to the Postanesthesia Care Unit

Information Often Given to the Nurse at the Time of Admission to the Postanesthesia Care Unit * Patient s name and age * Surgical procedure and type of anesthetic including drugs used * Other intraoperative drugs (antagonists, antibiotics,diuretics, vasopressors, antidysrhythmics) * Preoperative vital signs * Co-existing medical diseases * Preoperative drug therapy, including preoperative medication * Allergies * Intraoperative estimated blood loss and measured urine output * Anesthetic and surgical complications * Special medications or procedures that will be necessary in the postanesthesia care unit, including pain management,arterial blood gases, and radiolographs

Physiologic Disorders that May Manifest in the Postanesthesia Care Unit Upper airway obstruction Arterial hypoxemia Hypoventilation Hypotension Hypertension Cardiac dyshythmias Oligouria Bleeding Decreased body temperature Agitation (emergence delirium) Delayed awakening Nausea and vomiting Pain

Factors leading to Postoperative Arterial Hypoxemia Right left intrapulmonary shunt (atelectasis) Mismatching of ventilation to perfusion (decreased functional residual capacity) Decreased cardiac output Alveolaar hypoventilation (residual effects of anesthetics and/or muscle relaxants) Inhalation of gastric contents (aspiration) Pulmonary edema Pneumothorax Posthyperventlation hypoxia Increased oxygen comsumption (shivering) Advanced age Obesity Diagnosis * PaO 2 < 60 mmhg (arterial blood gas) * clinical S/S: hypertension, hypotension, tachycardia, bradycardia, dyshythmias, agitation are nonspecific. Low Hb impair detection of cyanosis Treatment * postoperative oxygen therapy * find causing factors ex; naloxone for residual opioid * tracheal intubation---if hypoxemia persists despite 100% O2 administration--- mechanically ventilation with PEEP

Postoperative Hypoventilation Etiology * drug-induced central nervous system depress (volatile anesthetics, opioids) * residual effects of muscle relaxants * suboptimal ventilatory muscle mechanics * increased production of carbon dioxide * co-existing chronic obstructive pulmonary disease Diagnosis * PaCO 2 > 44 mmhg (arterial blood gas) * sign---tachycardia and hypertension are nonspecific Treatment * maintain a patent upper airway * find causing factors than resolve it

Factors Leading to Postoperative Hypotension Arterial hypoxemia * hypovolemia (most common cause) * decreased myocardial contractility (myocardial ischemia, pulmonary edema) * decreased systemic vascular resistance (residual effects of anesthetics, sepsis) * cardiac dysrthmias * pulmonary embolus * pneumothorax * cardiac tamponade Dianosis and Treatment * oligouria (< 0.5ml/kg/h)---hypovolemia or decreased myocardial contractility * fluid challenge---cvp or PA pressure * inotropics (dopamine) and vasopressor (phenylephrine)

Postoperative Hypertension Etiology * arterial hypoxemia * enhanced sympathetic nervous system activity ( pain, bladder distension ) * preoperative hypertension * hypervolemia * pain Dianosis and Treatment * accuracy of the blood pressure measurement * find causing factors than resolve it * anti-hypertension drugs and arterial line monitor if necessary

Postoperative Cardiac Dysrhythmias Etiology * arterial hypoxemia * hypovolemia * pain * hypothermia * anticholinesterases * myocardial ischemia * electrolyte abnormalities hypokalemia ; hypocalcemia * respiratory acidosis * digitalis intoxication * preoperative cardiac dysrhythmias Treatment * correct underling cause, patent upper airway and adequacy of PaO2 * special drugs---atropine for bradycardia, verpamil for tachycardia, lidocaine for VPC s

Patient at High Risk of Postoperative Renal Dysfunction Co-existing renal disease Major trauma Sepsis Advanced age Multiple intraoperative blood transfusions Prolonged intraoperative hypotension Cardiac or vascular operations Biliary tract surgery in presence of obstructive jaundice

Possible Explanations for Delayed Awakening in the Postanesthesia Care Unit Residual drug effects (opioids, benzodiazepines, anticholinergics) Hypothermia Hypoglycemia Electrolyte disturbances Arterial hypoxemia Increased intracranial pressure (CVA) Air embolism Hysteria Treatment * find causing factors * special drugs---naloxone for opioid overdose, physostigmine for reversing CNS effects odf anticholinergic drugs and flumazenil antagonist for benzodiazepines

Factors Associated with an Increased Incidence of Postoperative Nausea and Vomiting History of postoperative emesis Female gender Obesity Postoperative pain Type of surgery (eye muscle surgery, middle ear surgery, laparoscopic surgery) Anesthetic drugs (opioids, nitrous oxide?) Gastric distension Treatment * R/O other causes ex: hypoxia, hypotension,hypoglycemia and IICP * prophylactic antiemetic for high risk patient---ondansetron 4-8mg iv, metoclopramide 10-20 mg iv less efficacy, transdermal scopolamine is good

Postoperative Respiratory Therapy Postooperative decrease in VC and FRC, poor cough, retension of secretions and atelectasis---pneumonia, hypoxemia Factors that influence the incidence of postoperative pulmonary complications--- site of surgery, co-existing pulmonary disease, cigarette smoking, obesity, and advanced age

Postoperative Respiratory therapy O 2 Therapy Nasal cannula---o 2 concentration is increased about 4% for each 1 l/min of O 2 delivered, max. 6 l/min (44% O 2 ) Face mask * simple mask---no valve or reservoir bag, can provide inhaled O 2 concentration between 35% and 60% with O 2 flow rate 5 to 8 l/min * partial rebreathing---valveless with O 2 reservoior bag, O 2 flows higher than 10 l/min, inhaled O 2 concentrations are between 50% and 65% * nonrebreathing---unidirectional valve plus an O 2 reservoir bag, inhaled O 2 concentration can increased to near 100%. Difficult to provide a sufficiently tight mask fit and the flow rate of O 2 into the system should be sufficient to maintain an inflated reservoir bag

Postoperative Respiratory Therapy Oxygen therapy Air-entrainment (venturi) mask---inhaled O 2 concentration 24-40% (2-12 l/min O 2 flow) Humidification and Aerosol therapy * bubble-through humidifiers---37 c relative humidity near 100% * jet nebulizers---humidity inspired gases, decrease the viscosity of airway secretions,and deliver bronchodilator drugs (epinephrine, albuterol) directly to the airways Bronchial hygiene mucocillary clearance; coughing; tracheal suctioning; chest physiotherapy Interventions to increase resting lung volumes voluntary deep breathing and ambulation; intermittent positive pressure breathing; incentive spirometry