Review of Systems

1
Review of Systems

• Anatomy, Physiology, and Complications

2
Preop respiratory assessment

• SpO2 on room air establishes a baseline.
• Respiratory history should include
• Smoking history pack years
• Chronic conditions
• Home O2 use, CPAP

3
Respiratory System

• Effects of anesthesia
• Halogenated anesthetics, muscle relaxants,
  propofol cause apnea.
• This is an expected effect of these drugs.
• Other agents (narcotics, benzos) cause
  respiratory depression.

4
Respiratory System

• The respiratory system is the first to be
  assessed on admission to PACU.
• Initiate oxygen delivery should come from OR
  with pulse ox and O2.
• The patient shall be continually evaluated and
  treated during transport with monitoring and
  support appropriate to the patients condition.
• Basic Standards for Postanesthesia Care
• http//www.asahq.org/For-Healthcare-Professionals/
  Standards-Guidelines-and-Statements.aspx

5
Assessment

• Listen to breath sounds on admission for general
  anesthesia patients.
• Is an ASPAN standard.

6
Items for Further Review

• Chapter 31 in Core Curriculum for discussion of
  oxygen delivery devices.
• Mechanical ventilation.
• Acid-base interpretation.

7
Respiratory Complications

• Residual obtundation after 15-30 min. is probably
  due to opioids, benzos.
• Partial airway obstruction or hypoventilation ?
  hypoxemia due to inadequate tidal volumes,
  atelectesis.

8
Respiratory Complications

• Treat with
• Oxygen and observation.
• Stir-up regimen.
• If necessary, reverse opioids and benzos with
  care.
• Reintubation and ventilation until adequate
  muscle strength.

9
Aspiration

• Primarily an intraoperative problem, but can
  happen in PACU.
• Is the most common, serious complication of
  anesthesia.

10
Residual neuromuscular blockade

• Risk factors
• Long-acting neuromuscular blocking agents.
• Inadequate reversal agents.
• PC deficiency.
• July and August.
• Signs and symptoms
• Air hunger.
• Discoordinated movements.
• Hypertension, tachycardia.
• Dysphagia.

11
Treatment

• More reversal in possible.
• Support airway,
• Reintubate pt until block has worn off.
• Sedate pt.

12
Aspiration

• Risk factors
• Nonfasted.
• GERD.
• Obstetric.
• Obese.
• Elderly immobilized pts.
• Emergency surgery increases the risk of
  aspiration 4 times over elective surgery.

13
Aspiration

• Pathophysiology of damage
• Acidic fluid is aspirated.
• Results in
• interstitial edema
• intra-alveolar hemorrhage
• atelectesis
• increased airway resistance
• hypoxemia

14
Immediate Management

• Lower head quickly.
• Turn head to side.
• Suction oropharynx.

15
Aspiration

• Will see symptoms within 2 hrs.
• Will see dyspnea, tachypnea, cough, fever,
  wheezing, rales, and hypoxemia.
• CXR will eventually see infiltrates, but not
  initially.

16
Treatment of Aspiration

• Airway patency, adequate ventilation, and
  supplemental oxygen.
• Pulmonary toilet and airway suctioning.
• Bronchoscopy may be indicated.
• Nebulized bronchodilators.
• Prophylactic antibiotics and corticosteroids are
  not indicated.

17
Stridor or Croup

• Noisy inspiration.
• Usually seen in infants or children because of
  smaller airways.
• Treatment
• Oxygen with humidification.
• HOB at 45-90?.
• Nebulized racemic epinephrine 2.25, 0.5 ml with
  3 ml NSS. May repeat q 30 min up to 3 times.
• Dexamethasone 0.5mg/kg IV q 6 hrs for moderate
  symptoms.

18
Laryngospasm

• Caused by a closure reflex of the vocal cords.
• Signs and symptoms
• High-pitched inspiratory stridor
• Tracheal tug
• Apprehension

19
Laryngospasm

• Treatment
• Oxygen with humidification.
• HOB at 45-90?.
• Lidocaine 1-1.5 mg/kg.
• Stay calm, and calm the pt.
• Have pt take short, shallow breaths.
• Bag-valve-mask device can break a spasm. Sux.
• Can cause negative pressure pulmonary edema.

20
Obstructive Sleep Apnea (OSA)

• Characterized by periodic, partial or complete
  obstruction of the upper airway during sleep.
• Cessation of airflow for more than 10 sec.,
  despite continuing ventilatory effort, 5 or more
  times per hr of sleep.
• Usually associated with a decrease in SpO2 of
  more than 4.

21
Obstructive Sleep Apnea

• Risk factors
• Obesity, especially with a neck circumference of
  ?15.5 16.5 inches.
• 60-90 of OSA pts are obese.
• 2 to 26 of the US population have OSA.
• 80 to 90 are unaware that they have it.
• Many are diagnosed during their pre-anesthesia
  assessment.

22
Obstructive Sleep Apnea

• In non-obese and pediatric pts, risk factors are
  craniofacial abnormalities, nasal obstruction,
  and large tonsils.

23
Signs and Symptoms of OSA

• Snoring, apnea during sleep, periodic snorting
  and arousal during sleep.
• Daytime sleepiness and fatigue.
• Hypertension.
• Personality and behavioral changes.
• Decreased cognition and intellectual function.

24
Diagnosis of OSA

• Sleep lab study which requires an overnight
  analysis.
• Apnea risk evaluation system (ARES) unicorder.
• Similar to a holter monitor.
• Records oxygen saturation, pulse rate, airflow,
  head position and snoring decibel level.

25
Screening Tools

• STOP-Bang
• Requires neck circumference.
• Must actually see patient.
• Berlin Questionnaire
• Can be done over the phone.
• ASA Checklist
• Requires physical exam of pt.
• American Sleep Apnea Association Snore Score
• Can be done over the phone.

26
Effects of Anesthesia and Surgery on OSA Patients

• Risk of airway obstruction following extubation.
• Spontaneous ventilation against an obstructed
  airway can cause negative pressure pulmonary
  edema.
• When extubated, should be fully awake, should
  have full recovery from neuromuscular blockade.

27
Postoperative Management

• Analgesia
• Be judicious with narcotics.
• Regional analgesia and epidurals.
• Oxygenation.
• Supplemental O2 until pt can maintain baseline
  SpO2.
• Continuous pulse oximetry if in-pt.
• CPAP after surgery if pt uses it at home.

28
Postoperative Management

• Positioning.
• Reverse trendelenberg in hospital.
• At home, sleep in lateral or prone position.
• Sitting position in recliner.
• Not supine.

29
In-Patient vs Out-Patient

• Outpatient OK when local or regional anesthesia
  used.
• TA in kids under 3 yo with OSA in-pt.
• In general, pts with OSA should be monitored for
  3 hrs longer than usual prior to discharge.

30
Obstructive Sleep Apnea

• Practice Guidelines for the Perioperative
  Management of Patients with Obstructive Sleep
  Apnea.
• http//www.asahq.org/For-Members/Practice-Manageme
  nt/Practice-Parameters.aspx
• Published in Anesthesiology, May 2006.
• Creating a Safer Perioperative Environment with
  an Obstructive Sleep Apnea Screening Tool
• L Lakdawala. JoPAN, Feb 2011, 15-24.

31
Asthma

• One of the most common chronic diseases in the
  US.
• Incidence and severity is increasing.
• An inflammatory disease of the airways.
• Asthma causes
• Airway wall thickening.
• smooth muscle contraction.
• Airway obstruction.
• Airway remodeling.

32
Treatment of Asthma

• Inhaled corticosteroids reduce the immediate and
  late phase responses to allergens, and actually
  prevent the airway remodeling.
• Sympathomimetic agents cause bronchodilatation,
  stimulate mucociliary transport, affect the
  function of inflammatory cells.

33
Effect of Anesthesia on Asthma

• All inhalational anesthetics produce
  bronchodilatation some are airway irritants.
• Some neuromuscular blocking agents cause
  histamine release.

34
Preop Management of Asthma

• Have pt bring his/her inhaler to hospital.
• Continue inhaled or systemic corticosteroids up
  to the time of surgery.
• A nebulized beta antagonist should be given prior
  to surgery.

35
Postop Management of Asthma

• Postop, assess the pt for s/s of asthma
  wheezing, diminished breath sounds, prolonged
  expiration.
• Anticipate giving a neb of albuterol.

36
Phase II Respiratory Care

• SpO2 on admission and on discharge from Phase II.
  Is NOT an ASPAN standard.
• For asthmatics, instruct them on when to use
  their inhaler.
• For kids after TA, tell parents to check their
  breathing when asleep, and to wake them up
  periodically.

37
Cardiovascular System

• Anesthesia has a profound effect on the CV
  system.
• Varies according to agent used.

38
Cardiovascular System

• Most halogenated anesthetics cause myocardial
  depression
• Decreased HR
• Decreased contractility
• Decreased CO
• Also cause
• Systemic vasodilatation

39
Hypertension

• Preop, obtain BP.
• Hypertension can be due to anxiety will resolve
  after surgery.
• Pts on antihypertensives should be told to take
  their med(s) the morning of surgery, except
  diuretics.

40
Postop Hypertension

• Significant hypertension should be reported to
  the anesthesiologist.
• Treat hypertension with analgesics as well as
  antihypertensives.
• May also be due to a full bladder.

41
Prevalence of CV Disease

• Many pts have underlying CV disease.
• Always be alert to intraop MIs, exacerbation of
  pre-existing conditions, angina.

42
Effects of Anesthesia on the CNS

• IAs produce an alteration of neuronal
  excitability.
• IAs cause cerebral vasodilatation and increase
  ICP.
• Are potent metabolic suppressants.
• Propofol produces cerebral vasoconstriction.

43
Neurologic Care

• Cerebral perfusion pressure
• Is a measure of the cerebral auto regulation,
  which maintains a relatively constant cerebral
  blood flow and ICP to provide adequate oxygen and
  nutrients to the brain.
• Need a minimum of 60 mm Hg systolic to provide
  minimally adequate blood flow to the brain.

44
Cerebral Perfusion Pressure

• CPPMAP-ICP
• MAPSBP DBP x 2
• 3
• ICP - 4-15 mmHg

45
Perioperative Visual Loss

• Permanent impairment or total loss of sight.
• Associated with spinal surgery, the prone
  position, and general anesthesia.
• Occur in less then 0.2 of spine surgeries.

46
Perioperative Visual Loss

• Risk factors
• Intraoperative hypotension.
• Substantial blood loss.
• Direct pressure to eyes from a sheet roll or
  headrest.
• Assess pts vision when pt becomes alert.
• Practice Advisory for Perioperative Visual Loss
  Associated with Spine Surgery
• http//www.asahq.org/For-Members/Practice-Manageme
  nt/Practice-Parameters.aspx

47
Effects of Anesthesia on Thermoregulation

• The hypothalamus regulates body temperature.
• Controls body temperature through effector
  mechanisms.
• Vasomotor.
• Metabolic.
• Sudomotor.
• Behavioral changes.

48
Effects of Anesthesia on Thermoregulation

• The hypothalamus is depressed.
• The IAs cause vasodilatation.
• The muscle relaxants, and to a lesser extent, the
  IAs, cause muscle paralysis, which prevents
  shivering.

49
Effects of Anesthesia on Thermoregulation

• No behavioral alterations are possible.
• With a spinal, the body is a poikilotherm below
  the level of the spinal.
• At or below a temp of 95? F, the bodys ability
  to rewarm itself is impaired.

50
Effects of Hypothermia

• Initially, causes vasoconstriction and
  hypertension.
• Later, causes bradycardia and diminished CO.
• Increased blood viscosity.
• Coagulation cascade and platelet function are
  impaired, esp. below 95?.

51
Effects of Hypothermia

• Hepatic function is depressed, resulting in
  slower clearing of anesthetic agents. A cold pt
  can reparalyze as he/she rewarms.
• Oxyhemoglobin dissociation curve is shifted to
  the left, resulting in reduced oxygen release to
  the tissues.

52
Effects of Hypothermia

• Temps below 95? cause impairment of short-term
  memory.
• Hypothermia also causes impaired wound healing.
• Maintenance of normothermia in colon surgeries is
  a Core Measure.
• A pt dissatisfier.

53
ASPAN Clinical Practice Guideline

• Prevention of Unplanned Intraoperative
  Hypothermia.
• Normothermia is 36? C (96.8? F). This is
  discharge temp. from PACU as well as Phase II.
• Begin rewarming in preop area.
• Continue rewarming in the OR.
• Treat hypothermia in PACU.

54
Effects of Hypothermia

• Shivering increases oxygen consumption by 500.
  Provide supplemental oxygen as long as the pt is
  shivering.
• Shivering probably represents an expression of
  neurological recovery or neurological hyper
  excitability after general anesthesia.

55
Effects of Hypothermia

• Treat shivering with Demerol, Stadol. Probably
  work by affecting a K receptor.

56
Neurological Assessment of General Surgery Pts

• Determine baseline LOC. Reorient to
  surroundings.
• If in Stage II, sedate until more coherent.
  Protect pt from themselves.
• Pt cannot be reoriented while in Stage II.
• Administer analgesics and let them wake up again.
• Expect pain offer and provide analgesia early.

57
Neurological Assessment After Neurologic Surgery

• For a detailed assessment, refer to Chapter 33 in
  Core Curriculum.
• Should see an increase in LOC. Be alert for a
  decreasing LOC, or appearance of new neurologic
  deficits.
• Maintain adequate oxygenation as well as
  normocarbia.

58
Neurological Assessment After Neurologic Surgery

• Maintain proper positioning, taking care of
  paralyzed limbs.
• Maintain normothermia. Prevent shivering when
  treating hyperthermia. Sponge baths with tepid
  water.

59
Neurological Assessment After Spinal Surgery

• Monitor for continued presence of intact SC.
• CSF is clear to slightly yellow. Pt will have
  signs of meningeal irritation headache,
  photophobia, nuchal rigidity.
• For anterior cervical procedures, monitor resp.
  status.

60
Diabetes

• The high carbohydrate levels that result from
  inadequate amounts of insulin stimulate lipid
  production, which eventually results in
  atherosclerosis.
• Diabetics have a much higher incidence of CAD and
  PVD than the general population. Atherosclerosis
  is diffuse and widespread.
• Have many other complications that can result in
  surgery.
• Have non-diabetic-related surgeries.

61
A1c

• HgA1c
• Glycosylated hemoglobin
• Is a 3-month measure of the blood sugar.
• 6 - 120 mg/dl
• 8 - 180 mg/dl
• 10 - 240 mg/dl

62
Insulins

• Lispro humalog
• a rapidly acting insulin analog.
• Has an onset of less than 15 min, peaks in 30 to
  90 min, and lasts for 2-4 hrs.
• Cannot be given IV.
• Regular insulin
• Onset of 30-60 min, peaks in 2-3 hrs, and lasts
  for 6-8 hrs.
• Can be given IV.

63
Long-acting insulins

• Lantus glargine
• Slow-acting insulin.
• Provides a constant baseline without peaks and
  troughs of action.
• Single injection lasts 20-30 hrs.
• Possibility of cancer risk.
• Levemir detemir
• Slow-acting insulin.
• Single injection lasts about 12 hrs.
• Once or twice a day dosing.

64
Insulin Pumps

• Act as an external pancreas.
• Provide a basal rate of insulin infusion.
• Can give boluses for meals, etc.
• Have pt leave them on for surgery.

65
Preop Insulin

• For insulin, take ½ usual dose.
• For oral agents, do not take.
• Check FSBS on admission to preop.
• IV is NSS.
• FSBS in preop, PACU and in Phase II prior to
  discharge.

66
Blood Sugars

• A slightly higher blood sugar is safer in the
  immediate postop period.
• The long term effects of high blood sugar in
  postop healing are profound.