Initial Diagnosis & Management

1. Examine & stabilize—check Airway, Breathing & Circulation

2. Fluid resuscitate—obtain adequate venous access

3. Review data—patient history, anesthesia record, surgical procedure, estimated blood loss, PACU data

4. Consider laboratory studies

• ABG—assess oxygenation & acid–base status

• CBC—assess hemoglobin & platelet level (also consider coagulation studies)

• ECG—assess for arrhythmias (also consider cardiac enzymes)

• CXR—rule out pneumothorax/hemothorax/cardiomegaly

• Blood cultures—esp if sepsis suspected

• Transthoracic/transesophageal echo—assess cardiac contractility, LV/RV function, LV filling, IVC collapse, valvular abnl

5. Consider invasive monitoring—arterial BP, CVP, pulmonary artery catheter

6. Initiate pressor/inotropic support—phenylephrine, norepinephrine, dopamine

7. Obtain consultations as needed—cardiology, ICU, surgery

Management of Specific Conditions

Hypovolemia

Myocardial Infarction/Ischemia

Bleeding

Common Causes

•  Cryoprecipitate if evidence of hypofibrinogenemia

•  Platelets if level <50,000–100,000 or previous exposure to antiplatelet agents

•  Consider use of recombinant factor 7 in uncontrolled, diffuse, postop bleeding

•  Assess for evidence of DIC (↓ fibrinogen, + FDP/D-dimer, ↑ PT/PTT, ↓ platelets)

→ Occurs in mismatch transfusion, placental abruption, intrauterine fetal demise, underlying malignancy, complex infections

→ Treat with transfusion of FFP, cryoprecipitate, & platelets

•  Maintain normothermia & consider calcium administration during massive transfusion

•  Alert OR personnel about need for possible take back

HYPERTENSION

Diagnosis and Management

•  Treat the underlying cause

•  Resume home antihypertensives as soon as possible

•  For initial management consider:

Labetalol 5–40 mg IV bolus q10min or

Hydralazine 2.5–20 mg IV bolus q10–20min or

Lopressor 2.5–10 mg IV bolus

•  For severe hypertension, consider vasodilator infusion

Sodium nitroprusside (0.25–10 mcg/kg/min) or

Nitroglycerine (10–100 mcg/min)

Esmolol, nicardipine, cardizem infusions may also be used

RESPIRATORY AND AIRWAY PROBLEMS

Respiratory Insufficiency: Diagnosis & Management

1. Assess Airway, Breathing, Circulation

2. ↑ delivered FiO₂, ↑ flow rate & consider non-rebreather or shovel mask

3. Consider jaw thrust/chin lift, placement of oral/nasal airway

4. Consider positive-pressure ventilation with bag-valve mask

5. Consider intubation vs. noninvasive ventilation (CPAP/BiPAP)

6. Review pt history, OR & postop course, fluid status, & medications administered

7. Consider ABG, chest x-ray (rule out pneumothorax/pulmonary edema)

Respiratory Insufficiency: Management of Specific Conditions

Hypoventilation

NEUROLOGIC PROBLEMS

Common Problems: Delayed awakening, emergence delirium/confusion, anxiety/panic attack, peripheral neuropathy

Delayed Awakening (see Chapter 10, Common Intraoperative Problems)

PACU DISCHARGE CRITERIA

•  PACU discharge criteria usually based on modified Aldrete score (Anesthesiology 2002;96:742)

•  Clinical judgment should always supersede any score or criterion

•  Postanesthesia recovery is divided into 2 phases

Guidelines for Discharge From Phase 2

•  Redocumentation of vitals, postanesthesia recovery score

•  Acceptable surgical site condition

•  Adequate pain control (<3 out of 10 or tolerable)

•  Ability to ambulate

•  Recovery from regional anesthesia (except for peripheral nerve block)

•  Discharge to a responsible adult

•  Postanesthesia recovery score of ≥9

•  Written & verbal instructions provided prior to discharge

Common Discharge Issues (Anesthesiology 2002;96:742–752)

•  Passing of urine is not a mandatory requirement

•  Ability to drink and retain fluids is not mandatory

•  There is no minimum PACU stay period

•  Escort is needed if pt received any sedation

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