1. Care of the Post-Surgical Patient
Chapter 20 (p.366)
Priorities & Potential Problems

2. Beginning with PACU
Patient stays in PACU until motor/sensory function return, pt. is oriented, stable vital signs, no hemorrhage, no complications
Priorities; maintaining a patent airway, cardiovascular stability

3. Initial PACU Assessments
Airway
-Ensure patency
Breathing
-RR/depth, breath sounds, pulse oximetry
Circulation
-Continuous ECG monitoring, BP, temp., pulse quality
Neurologic
-LOC, orientation, pupils, sensory/motor
Genitourinary
-I&Os, urinary retention
Surgical incisions, dressings, & drains
Pain
-Location, quality

4. Airway Complications Obstruction Retained Secretions Laryngospasm
Laryngeal Edema
See page 369

5. Airway Obstruction
- Most common cause tongue falls backward against the soft palate signs; stridor, snoring, coughing, decreased SA02, decreased LOC, blue dusky color - Tilt head back push forward on angle of lower jaw - May have oral airway in place to help prevent. Should not be removed until signs of gag reflex return

6. Airway Obstruction Continued: Laryngospasm
- Irritation from ETT or anesthetic gases - Monitor for stridor, sternal retractions, acute respiratory distress - Treatment; Positive pressure ventilation, corticosteroids, lidocaine, IV muscle relaxants

7. Other Respiratory Complications
Hypoxemia
-PaO2 less than 60 mm Hg
-Potential causes- atelectasis, pulmonary edema, PE, aspiration, bronchospasm
-Clinical manifestations may include agitation, disorientation, hypo/hypertension, tachy/brady, cardiac dysrhythmia, dyspnea

8. Other Respiratory Complications
Hypoventilation
-Inadequate respiratory drive and/or functioning of respiratory muscles
-May be result of oversedation, pain management issues, and/or mechanical restriction from casts, dressings, or position

9. Cardiovascular Complications
Hypotension
Hypertension
Cardiac Dysrhythmias

10. Hypotension
Most often caused by a decreased in circulating blood volume (due to unreplaced fluid/blood losses)
Anesthetic/sedative agents may affect BP
May be caused by cardiac dysrhythmias
PE, sepsis and transfusion reactions
How would you treat post-opertative hypotension?

11. Hypertension
Secondary to SNS stimulation from pain, respiratory compromise, or bladder distension
Other causes; hypothermia, anxiety, fluid overload, wrong size cuff, baseline HTN and skipped med prior to surgery
Treatment: Short acting vasodilators like- hydralazine, nifedipine

12. Cardiac Dysrhythmias
Potential Causes: Hypoxemia, hypercapnia, electrolyte imbalances, circulatory instability, heart disease, hypothermia, pain, surgical stress, & anesthetics

13. Thermoregulation Complications
Hypothermia
Hyperthermia
Malignant Hyperthermia

14. Hypothermia Less than 35°C, (95°F)
Causes: NMB (prevents shivering), heat loss from exposure, cold irrigating and IV solutions
Elderly, debilitated, and intoxicated patients at increased risk
Complications include impaired wound healing, cardiac compromise, bleeding, post-op pain shivering and pain, altered drug metabolism

15. Hyperthermia
39°C., (102.2°F)
Environment, blankets, drapes, inhalation anesthetics
Infection, septicemia

16. Malignant Hyperthermia
Most cases occur when both volatile inhaled anesthetics and succinylcholine are used
Can manifest intra-op or post-op
Can be a familial link (autosomal dominant trait)

17. Malignant Hyperthermia Continued
Hypermetabolism of skeletal muscles resultant from altered control of intracellular calcium
Manifestations- hyperthermia, hypoxemia, lactic acidosis, hemodynamic/cardiac alterations
Treatment: Dantrolene sodium!, removal of causal agents, cooling measures (requires large team of staff to appropriately treat patient)
Page 363

19. GI Complications Nausea & Vomiting
-Common in immediate post-op period
-Leaves the patient with a lasting unpleasant memory
-May require admission for post-out-patient surgery patients
-Concern for aspiration
-Treatment; antiemetics, protecting airway

20. Postoperative Pain IV titration of opioids Toradol PCA
Epidural analgesia (less sedating) Morphine, hydromorphone, fetanyl

21. Bupivicaine

22. Gerontologic Considerations
Decreased respiratory function
Decreased cough effort
Decreased thoracic compliance
Decreased lung tissue
Compromised cardiac function and impaired compensatory mechanisms
Impaired renal and liver function can increase risk for drug toxicity, oversedation
Increased risk for post-op delirium (15-53% cases)

23. Discharge from the PACU
Aldrete scoring system
8 -10 score needed
Scored 0-2 in each of the following categories; Activity level (extremity movement), respiration, circulation (post-op BP compared to baseline BP), consciousness, oxygenation (saturation and amount of supplemental o2 required)