PACU Care in the ICU SePA Conference 2012 Cathy Case MSN RN CPAN Amy Luckowski PhD(candidate) RN CCRN
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
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 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)