Perianesthetic Care Preadmission Preop Phase Phase I Phase II Phase III
Preadmission Programs • Provide comprehensive assessment and teaching. • Obtain lab work, EKG, CXR, other tests as applicable. • Issues that need follow-up prior to admission – minimizes cancellations. • May need clearance from cardiologist, pulmonologist, others.
Preadmission Programs • Identify high-risk pts. • History and physical. • Preop teaching. • Requirements after surgery.
Meds, OTCs and Herbals • ASA, NSAIDS, coagulants • Diabetic meds • Beta blockers; last time taken. • Vitamin. E, fish oil, many herbals affect coagulation.
Preadmission Programs • Can be done with a clinic. • Advantage is written material and hands-on assessment. • Can use different teaching methods. • Pediatric pts can tour facility. • Not all pts will be able to attend. • Can be done with a preop phone call. • Be careful with message left on answering machine.
Preadmission Programs • Can be web-based. • Can include registration. • Advantages: • Proceed at own pace with no interruption of schedule. • Can review and print information. • Disadvantages: • No web access. • No one for questions.
ASA Guidelines for Anesthesia • Category 1 – normal, healthy. • Category 2 – pt with mild systemic disease (NIDDM, mild hypertension). • Category 3 – pt with severe systemic disease ( CAD, IDDM, morbid obesity).
ASA Guidelines for Anesthesia • Category 4 – pt with severe systemic disease that is a threat to life (chronic CHF, advanced pulmonary insufficiency). • Category 5 – morbid pt who is not expected to survive without the operation. • Category 6 – a declared brain dead pt whose organs are being harvested. • E – emergency.
Selection of Pts for OPS • Know the policies and procedures of the institution, including age criteria. • ASA 1, 2, 3. • Surgical procedure.
Preoperative Phase • History and assessment • Medical history and physical. • Nursing data collection, including pain hx. • Baselines • Allergies • Meds, including OTCs and herbals • Medication reconciliation • Pregnancy status • Fall risk
Preoperative Phase • Perform needed tests. • Obtain signature on needed permits. • Site verification. • Determine availability of transportation home, and an adult caretaker. • Determine NPO status. • Initiate IV. • Preop meds.
Prevention of Intraop Hypothermia • SCIP recommendation. • Begins in preop area. • Maintenance of normothermia. • An ASPAN Clinical Practice Guideline.
Non-English Speaking Pt • Have a legal obligation to provide preop instruction, op permit, and postop education in native language. • Identify head of family; direct conversation to that person. • Be familiar with common ethnic cultures in your facility.
ASA Practice Guidelines for Preoperative Fasting • Were released by the ASA in January 1999. • No fried or fatty foods or meat for 8 hrs before a procedure. • May have a light meal 6 hrs before a procedure. • Light meal is toast and clear liquids – tea and toast.
ASA Practice Guidelines for Preoperative Fasting • May take clear liquids up to 2 hrs before a procedure. • Clear liquids are water, fruit juices without pulp, carbonated beverages, clear tea and black coffee.
ASA Practice Guidelines for Preoperative Fasting • For breast-fed infants, may take breast milk until 4 hrs before procedure. • For infants using formula, may take formula until 6 hrs before procedure. • Completely NPO at 2 hrs before a procedure.
Easy Way to Remember • 8-6-4-2 • 8 hr – no solid food. • 6 hr – no formula. • 4 hr – no breast milk. • 2 hr – completely NPO.
If these guidelines are not followed, can result in hypovolemia the day of surgery. • Esp. true with afternoon surgeries. • Is also a patient dissatisfier to be NPO from 2400 til afternoon surgery.
Shaving vs. Clipping • Shaving results in microscopic nicks that can result in bacterial growth. • Clipping results in less skin nicks. • Clipping is recommended by the AORN, and by the Guidelines for Prevention of Surgical Site Infections published by the CDC in 1999. • A SCIP criteria.
Pts with a DNR • Talk to pt and family, usually by anesthesia provider. • Many facilities suspend the DNR during surgery through PACU stay. • DNR is reactivated after discharge from PACU. • http://www.asahq.org/For-Healthcare-Professionals/Standards-Guidelines-and-Statements.aspx
Handoff • Method determined by facility. • Face to face • Phone • Written report • Combination
Equipment Needs • Preop • Fully stocked crash cart with adult and pediatric paddles • Pacing capability • Phase I • All of the above and • MH cart • Ventilator readily accessible
Phase I • Is a critical care area. • Receive report from OR RN and anesthesia provider. • Come from OR with pulse ox and O2? • Assess breath sounds.
Oral Airway • Remove as soon as the pt wakes up. • To insert an OA: • Turn it up side down and insert into the mouth. • While advancing the OA, turn it 180. • For children, turn it 90 . • Slide it over the tongue.
Nasal Airway • Provides a conduit from the nares to the base of the tongue. • Prior to insertion, examine both nares. • Lubricate with KY or 2% Xylocaine. • Push upwards and backwards on the nose. • Slide the long tip along the nasal septum and the floor of the nasopharnyx to avoid trauma to the middle turbinate. • Can be tolerated by awake pts.
Extubation • Awake, VS stable, T96, resp. rate 24. • Head lift for 5 sec. • Hand grip for 5 sec.
Extubation • Suction oropharynx. • Hyperoxygenate. • Deflate cuff (don’t pull the balloon off). • Have pt cough. • Remove ET. • Apply supplemental oxygen. • Monitor for SOB, stridor, dyspnea.
Removal of LMA • Should be done with pt deeply anesthetized, or awake. • Not done with pt in halfway stage. • Don’t suction prior to extubation, but may need to do so afterwards. • Swallowing is a sign that LMA can be removed.
Reflexes as a guide to depth of anesthesia • Reflexes come back in this order: • pupillary lid or corneal reflex swallow cough.
Pulmonary Toilet • Treatment of hypoxemia. • Stir-up regimen. • CDB. • Taking a deep breath and holding for 1 sec. is more effective than coughing in treating atelectesis. • Incentive spirometry: Take 1 breath on the IS, then take 2-3 normal breaths.
Initial Postop Assessment • Frequency of vital signs. • If the readings are not within normal limits, determine what the pt’s preop BP and HR were.
Bradycardia • Is the pt symptomatic? • What are preop HR and BP? • Atropine. • Robinul.
Tachycardia • Many times, do nothing. Tincture of time. • Consider influencing variables – anxiety, iatrogenic hyperthermia, presence of epinephrine in local anesthetics used in the nose or face, full bladder. • Use non-pharmacologic measures.
Hypertension • Cannot ‘cure’ chronic hypertension. • Opioids. • Can cause stroke, severe hypotension, AMI, conduction disturbances.
Hypotension • Most common cause is hypovolemia. • Is especially true of afternoon surgeries when the ASA NPO guidelines are not followed. • Hypovolemia causes other problems – PONV, postural hypotension, inability to void.
Adult Fluid Replacement Formula • Deficit: the time the pt is NPO to the time the surgery begins. • 4 ml/kg/hr for the first 0-10 kg • 2 ml/kg/hr for the next 11-20 kg • 1 ml/kg/hr for weight greater than 21 kg
Adult Fluid Replacement Formula • Maintenance: Depends on the type of surgical procedure. • Eye, extremity 5 ml/kg/hr. • Mastectomy 8 ml/kg/hr. • Minor abd. (appy, hernia) 8-10 ml/kg/hr. • Laparotomy, thoracotomy 12 ml/kg/hr. • Extensive – Whipple 15-20 ml/kg/hr. • 2004 RediRef
Temperature • Assess of admission and discharge from PACU. • Active rewarming devices. • Check temp every 15 min. while rewarming. • Stop rewarming when temp is 96.8 or 36. • Keep head covered. • Supplemental oxygen while shivering.
Assessment of Operative Site • Surgery-specific observations.
Neurological Assessment of General Surgery Pts • Determine baseline LOC. Reorient to surroundings. • Hearing is the first sense to return. • Intra-op stroke or VTE.
Delayed Awakening • Meds: benzos, analgesics, ketamine. • Preop meds, supplements. • Respiratory inadequacy – rising CO2. • Intraop stroke.
Emergence Delirium • Dysphoria is the hallmark of Stage II of anesthesia • Signs and symptoms: • Restlessness • Thrashing • Combativeness • Crying, moaning, and/or screaming. • Fecal and/or urinary incontinence.
Emergence Delirium • Negative effects: • Injury of self – extremities, tongue. • Pull IV out. • Pull ETT out. • Disrupt suture lines.
Emergence Delirium • Treatment • Opioids to put them back to sleep. • Speak in reassuring tones. • Physical restraints as a last resort.
Postop Pain • Expect pain after surgery. • Offer opioids early. • Use a pain scale. • Use descriptive scale before pt is aware enough to rate pain. • If analgesics are not decreasing pain, look for preop pain rating and preop use of opioids. • Consider use of preop non-opioid meds.
Nausea/Vomiting • As soon as the pt complains of nausea, turn the IV up. • Be aware of hx of CHF. • Administer anti-emetics. • Alcohol swab over nose. • Ginger ale.
Family Visitation in PACU • . . . visitation in the Phase I level of care is supported, and that perianesthesia nurses develop guidelines within their own settings to incorporate this into their practice.
Guidelines for Visitation in PACU • Appropriate education for families. • Confidentiality of all pts will be maintained. • Visit will occur at an appropriate time for pt, visitor, and staff.
Guidelines for Visitation in PACU • Perianesthesia nurses should work . . . to establish a family visitation program supported by appropriate personnel.
Discharge from PACU • Must be discharged by an anesthesiologist OR • Discharged by criteria as approved by the Department of Anesthesia. • The PACU nurse shall determine the pt meets discharge criteria. • This should be stated on the PACU anesthesia orders.