PACU Care in the ICU

SePA Conference 2012 Cathy Case MSN RN CPAN

Amy Luckowski PhD(candidate) RN CCRN

Anesthesia Continuum p Awake p Minimal Sedation p Moderate Sedation p Monitored Anesthesia Care (MAC) p  Total IV Anesthesia (TIVA) p Regional Anesthesia p General Anesthesia

ASA Score p  I Healthy patient p  II Mild systemic diseases p  III Severe systemic diseases p  IV Severe systemic diseases – life

threatening p V Patient unlikely to survive p  E Emergency

Stages of Anesthesia p Stage 1 – stage of anesthesia & amnesia p Stage 2 – stage of delirium p Stage 3 – stage of surgical anesthesia p Stage 4 – cessation of respiration to

circulatory collapse

MAC and TIVA p Common Procedures

p Common Medication n  Midazolam (Versed) n  Propofol (Diprivan) n  Etomidate (Amidate) n  Fentanyl (Sublimaze) n  Ketamine

p Reversal agents n  Naloxone (Narcan) n  Fluzazenil (Romazicon)

p Recovery

n  Frequent vital signs with pulse ox n  Stir up regime

Regional Anesthesia: Spinal or Epidural p  Technique p Dermatomes and

Common landmarks p Sequence of spinal loss

and return of function

Pharmacology p  Esters

n  Procaine (Novacaine) n  Tetracaine (Potocaine)

p Amino-amides n  Prilocaine (Citanest) n  Lidocaine n  Bupivacaine (Marcaine, Sensorcaine) n  Ropivacaine (Noropin)

p Additives

Nursing Implications with Spinals/Epidurals p Hypotension

n  Fluids n  Raise legs n  Vasopressors

p  Neosynephrine (phenylephrine) p  Ephedrine Sulfate

p Bradycardia

Nursing Implications with Spinals/Epidurals – cont.

p Neurological complications n  Seizures, change in mental status n  Postdural puncture Headache

p Respiratory effects p Discharge afterwards

General Anesthesia p Mask p Airways

n  Endotracheal Tube n  LMA n  LMA Supreme

Inhaled Agents p Nitrous Oxide p Sevoflurane (Ultane) p Desflurane (Suprane) p  Isoflurane (Forane)

Neuromuscular Blocking p Muscle Relaxants p Action p  Two types

n  Depolarizing n  Nondepolarizing

p  Train of Four

Depolarizing Muscle Relaxants p Succinylcholine (Anectine)

n  Short acting 3-5 minutes n  No reversal but time

p  Pseudocholinesterase deficiency n  Different levels of deficiency n  Causes prolonged blockage n  May require ventilator support n  Maybe an ICU admission

Non-depolarizing Muscle Relaxants p Many agents

n  Rocurium (Zemuron) n  Vecuromium (Norcuron) n  Pancuronium (Pavulon) n  Nibex (Cisatracurium)

p Reversal Agents n  Neostigmine (Prostigmin) n  Glycopyrrolate (Robinul) or atropine

p Nursing Implications

Modified Aldrete Score p  Activity p  Respiration p  Circulation p  Consciousness p  Color or Oxygenation p  Dressing p  Pain p  Ambulation p  Fast feeding p  Urine output

Nursing Considerations p  Airway

n N/C n Humidified O2 mask n  Intubated n Adjunct airways n Chin lift

p Breathing

n Hypoventilation n Hypoxia n Laryngospasm

p Partial or complete spasm of vocal cords

p Risk: smoking, difficult intubation, COPD, vocal cord surgery

p Management

p Circulation Hypotension Hypertension Cardiac Dysrhythmias

p Dressings and Drains

p  Emergence Delirium n At risk: young, old, anxious n Associated with ketamine,

anticholinergics, barbituates, and benzodiazepines

n Other causes: hypoxia, hypothermia, hypoglycemia, and hypoventilation

n Tx: fix cause, sedation, reassurance

p  Glycemic control n Hyperglycemia increases postop

complications: p labile BP, p dysrhythmias and cardiac ischemia p infection p delayed wound healing

n BS goal

p  Hypothermia n  Less than 36° C (96.8° F) n  Adverse effects n  Shivering n  Forced air convection system n  Warm blankets

p  Malignant hyperthermia n Genetic disorder and hypermetabolic

response to inhalation agents n Triggers n S/S: muscle rigidity, HR, RR, end tidal

CO2, cyanosis, K, acidosis, and temp n Dantrolene sodium n 1-800-MH-HYPER

p Nausea: 10-50% n Causes

p Anesthesia p Opioids p Full stomach p Abdominal, head, and neck surgeries

n Adult risk factors p Female p Prior motion sickness or PONV p Nonsmoker p Use of peri-operative opioids

Nausea TX: p  Fluid replacement: 15-40 ml/kg p Antiemetics:

n  Ondansetron (Zofran) n  Inapsine (Droperidol) n  Prochlorperazine (Compazine) n  Promethazine (Phenergan) n  Metroclopromide (Reglan) n  Dexamethasone (Decadron) n  Scopolamine patch n  Diphenhydramine (Benadryl)

p Pain control n Narcotics n Ketorolac n PCA n Epidural

n Surgical Care Prevention Project p DVT’s p Normothermic p Beta Blockers p Glucose control

Questions?