Upload
dinhhuong
View
224
Download
3
Embed Size (px)
Citation preview
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)