MANAGEMENT AND DISCHARGE


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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Jul 4, 2016 | Posted by in ANESTHESIA | Comments Off on MANAGEMENT AND DISCHARGE
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