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Post Operative Arterial Hypoxemia. Oren Erlichman, M.D UCLA Department of Anesthesiology. PACU Patient. 73 yo female with hx of depression and chronic cholesthiasis underwent GA for biliary duct leak repair. Presented to PACU in respiratory distress.

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post operative arterial hypoxemia

Post Operative Arterial Hypoxemia

Oren Erlichman, M.D

UCLA Department of Anesthesiology

pacu patient
PACU Patient
  • 73 yo female with hx of depression and chronic cholesthiasis underwent GA for biliary duct leak repair.
  • Presented to PACU in respiratory distress.
  • Noted to be weak, altered, unable to talk, with poor inspiratory effort.
  • VS: 142/83, 114, 15 and shallow, 91-93% on FM.
pacu patient continued
PACU Patient – Continued
  • Review of Anesthesia chart:
    • GA, sevo, nitrous, ETT, 3hrs.
    • 150mcg of fentanyl at beginning of case, 0.4 of dilaudid at the end of case after spontaneous breathing.
    • 50mg of rocuronium at beginning of case, then vecuronium titrated with nerve stimulator, then fully reversed to sustained tetanus.
    • Extubated once followed command to eye opening.
pacu patient studies
PACU Patient Studies
  • ABG – 7.20/83/81/25/93.2
  • Other labs normal except for increase in Crt from 0.9 to 1.5.
  • CXR, EKG – normal.
  • Rechecked twitches with nerve stimulator – 2mg of Neo/0.4 of Glyco given in PACU.
causes of arterial hypoxemia in the pacu
Hypoventilation

Residual narcotics

Residual benzos

Residual inhaled anesthetics

Residual muscle relaxants

Pain, splinting

Restrictive Conditions, abdominal wall binding, abdominal distension

Airway obstruction

Bronchospasm

V/Q mismatch and Shunt

Atelectasis

Inhibition of Hypoxic Pulmonary Vasoconstriction.

Pulmonary edema

Aspiration, Pneumonitis

Increased Venous Admixture

Causes of Arterial Hypoxemia in the PACU
how does hypoventilation cause hypoxemia
How Does Hypoventilation Cause Hypoxemia?
  • The alveolar gas equation

PaO2= FIO2 (Patm-PH2O) – PCO2/R

If PaCO2=40

PaO2= 0.21(760-47) – 40/0.8 = 100

If PaCO2=80

PaO2= 0.21(760-47) – 80/0.8= 50

how does hypoventilation cause hypoxemia1
How Does Hypoventilation cause Hypoxemia?
  • Normally there is a linear increase in minute ventilation for increase in CO2.
  • This linear ventilatory response is blunted in the post operative period by the effects of drugs.
how does v q mismatch and shunt cause arterial hypoxemia
How does V/Q mismatch and shunt cause arterial hypoxemia?
  • Alveoli that are either not getting perfused or not getting ventilated affect the transport of oxygen.
  • The diffusion capacity of oxygen is limited compared to that of carbon dioxide.
treatment identify the underlying cause
Hypoventilation

Reversal of drugs

Decrease dead space ventilation

Supplemental O2

Mechanical ventilation

V/Q Mismatch and Shunt

Sitting position

Incentive Spirometry

Encourage deep breathing.

Positive airway pressure

Supplemental O2, although not effective in true shunt.

Mechanical Ventilation

TreatmentIdentify the Underlying Cause
pacu patient course
PACU Patient - Course
  • Patient was assisted with AMBU bag intermittently for 2hrs, with some improvement in mental status and saturation.
  • Eventually patient was intubated, transferred to ICU and extubated the next day.