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POstOPerAtive AnesthesiA CAre unit (PACu) And COMMOn POstOPerAtive PrObleMs ● 437 Treatment includes a number of modalities. An essential part of therapy is treating underlying factors (e.g. hypotension, hypoglycemia, elevated ICP, and GI bleeding). Serotonin receptor blockers, such as ondansetron 4 mg IV, at the end of surgery have few side effects and are commonly used. Dexamethasone, a steroid, is also a useful antiemetic, although its exact mechanism of action is unclear. It is given as a 4–8 mg IV dose just after induction. Droperidol is useful for breakthrough nausea, but may lead to sedation and currently has an FDA mandated black box warning due to Q-T interval prolongation. Compazine, metoclopramide, and phenergan are also available medications (see Chap. 7, Pharmacology of Adjunct Agents). Multimodal therapy (i.e. drugs from several different classes) and prevention is most effective in the treatment of PONV. Pain Control A plan for controlling postoperative pain depends on both patient and surgical factors. Pain medications can be given via intravenous, intramuscular or oral route. The intravenous route is often preferred because medications can be given in smaller doses, have more reliable uptake, and are more easily titrated. Common opioids and their basic properties are listed in Table 27.8. Patients who had a regional block placed may require fewer supplemental medications. Patients who have an epidural placed for postoperative pain may receive both the local anesthetic and the opioid via the epidural catheter. Non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and COX-2 Inhibitors are other classes of medications that are also very useful in the postoperative setting. Potential benefits include reducing opioid requirements, decreasing the incidence of nausea and vomiting, minimal effect on platelet function (COX-2 inhibitors), and fewer gastrointestinal side effects. Table 27.8 Commonly used opioids in the PACU. Drug Duration Typical bolus dose Fentanyl short acting 25–100 mcg iv hydromorphone (dilaudid) intermediate to long duration 0.2–1 mg iv Meperedine (demerol) intermediate to long duration 50–100 mg iv/sC/iM Morphine intermediate to long duration 2–5 mg iv
438 ● AnesthesiA student survivAl Guide Ketorolac (Toradol) is a popular analgesic, but potentially deleterious side effects include platelet dysfunction and nephrotoxicity. It should be used with caution in patients with renal dysfunction, the elderly or those with increased risk of bleeding. Hypothermia and Shivering Hypothermia and shivering can result from a number of causes. Distributive heat loss, evaporation from skin prep, impaired function of normal thermoregulation from anesthetics and the higher rate of heat loss from patients with burns, traumatic injuries, or cachexia can all lead to a significant drop in body temperature and subsequent shivering. The physiologic impairments of both hypothermia and shivering are detailed below in Table 27.9. The treatment of hypothermia and shivering includes forced air warming devices, patient reassurance, and meperidine in severe cases of shivering. Discharge Criteria Discharge from the PACU is based on an array of clinical factors outlined below: General Condition The patient should be oriented to time, place, situation, and follow commands. Patient should be non-cyanotic and non-pallorous, and muscle strength needs to be appropriate. Nausea, pain, and any other major early postop complications should be absent or under control. Table 27.9 Effects of hypothermia and shivering. hypothermia • Increased oxygen consumption, carbon dioxide production • Elevates peripheral vascular resistance • Impairs platelet function, decreased clotting factors • Increased infection rates • May lead to cardiac dysrhythmias shivering • Increased oxygen consumption (up to 200%) • Increased carbon dioxide production (up to 200%) • Impairs monitoring devices • May lead to myocardial ischemia • May precipitate ventilatory compromise
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Anesthesia Student Survival Guide
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Editors Jesse M. Ehrenfeld, MD, MPH
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Foreword As anesthesiologists and H
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Contents Case Studies xvii Section
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ContEntS ● xi 19 Physiology and A
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Contributors Basem Abdelmalak, MD S
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David C. Lai, MD Partner, Allenmore
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CASE STUDIES In order to focus your
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CASE StUDIES ● xix inhalation ane
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CASE StUDIES ● xxi around the job
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CASE StUDIES ● xxiii ● Although
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CASE StUDIES ● xxv ● You plan a
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CASE StUDIES ● xxvii ● What oth
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CASE StUDIES ● xxix Chapter 23 Ca
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CASE StUDIES ● xxxi of her left h
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CASE StUDIES ● xxxiii speechless.
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CASE StUDIES ● xxxv things go ver
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How to Be a “Star” Student, Car
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hOw tO Be A “stAr” student, CAr
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Pre-Op Holding Area Preoperative Ev
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History of Anesthesia and Introduct
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history of AnesthesiA And introduct
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Pharmacology Section II
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The Preoperative Patient Evaluation
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THe PreoPerATIve PATIenT evAluATIon
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Therapy-based indications radiation
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Table 8.5 Formulation an anesthetic
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Anesthesia Equipment and Monitors B
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AnesthesiA eQuiPment And mOnitOrs
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● ● ● AnesthesiA eQuiPment An
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Table 11.3 Data typically obtained
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Anesthetic Techniques: General, Sed
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Anesthetic techniques: GenerAl, sed
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Table 12.2 Stages of general anesth
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Table 12.6 (continued) Anesthetic t
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Anesthetic Techniques: Regional Ant
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Figure 13.2 Surface anatomy for neu
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Table 13.1 Risks of neuraxial anest
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Anesthetic techniques: reGionAl ●
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Table 14.6 Advantages, disadvantage
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Table 14.11 Transfusion of bloodpro
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Chapter 15 IV, Gastric Tube, Arteri
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iv, GAstric tube, ArteriAl & centrA
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Common Intraoperative Problems Fran
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Pneumothorax Uncommon, but may spon
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COMMON INTRAOPERATIVE PROBLEMS ●
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Table 16.3 Common intraoperative dy
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Table 16.3 (continued) Problem Diff
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Systems Physiology and Anesthetic S
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Chapter 20 Physiology and Anesthesi
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PhysioloGy And AnesthesiA for Gener
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Anesthesia for Urological Surgery P
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AnesthesiA for uroloGicAl surGery
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Physiology and Anesthesia for Pedia
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PhysioloGy And AnesthesiA for PediA
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Table 22.6 Common pediatric emergen
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Physiology and Anesthesia for Elder
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PhysioloGy And AnesthesiA for elder
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Chapter 24 Ambulatory Surgery and O
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AmbulAtOry Surgery ANd Out-Of-Or (O
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Page 434 and 435: Perioperative Acute and Chronic Pai
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QuAlity AssurAnce, PAtient And Prov
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Chapter 32 Clinical Simulation in A
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Table 32.1 Matrix of categories of
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CliniCAl simulAtion in AnesthesiA e
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ASA Difficult Airway Algorithm Appe
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518 ● ANESTHESIA STUDENT SURVIVAL
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