PACU Emergenies

PACU Emergencies

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By Dr Ronak Patel and Dr Rahim Esmail

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Teaching package information

PACU Emergencies

Objectives

Duration

Each unit has its own list of objectives. A case based approach is used. Overall course objectives are shown on the next slide.

There is about 6 hours of material in total to get through. We reccomend splitting this over several days,

Dr Ronak Patel

Assessment

Target Audience

Each unit has an assessment section to test you knowledge at the end. There is an overall assessment at the end.

PACU Nurses working in an operating theatre environment.

Dr Rahim Esmail

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Teaching Package

Overall Objectives

To become more familar with common PACU emergenies.

Management

Background

Identification

To gain skills and knowledge in identifying emergency siutations, including identifying risk factors.

To understand and contribute to emergency management.

To have more understanding about why emergencies scenarios in the PACU setting may occur

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Unit Menu

Unit 1 A breathless bowel resection

Unit 2: An Itchy inguinal hernia repair

Unit 3 A sleepy shoulder replacement

Unit 4: A hypotensive hysterectomy

Unit 5: A noisy nephrostomy

Final Assessment

UNIT 1

A breathless bowel resection

Unit 1

A breathless bowel resection

Handover

A 74 year old man, with a history of hypertension, chronic kidney disease and ulcerative colitis has undergone an emergency laparotomy with a bowel resection for a bowel perforation, The surgery was uncomplicated. He was anaesthetised with a GA and endotracheal tube. He was extubated in theatre prior to transfer to the recovery area. Medications Administered: 15:00 Fentanyl 100mcg (on induction) 15:01 Propofol 200mg (on induction) 15:01 Rocuronium 90mg (on induction) 17:40 Paracetamol 1g 17:45 Ondansetron 5=4mg 18:00 Morphine 15mg 18:10 Sugammadex 200mg

Unit 1

A breathless bowel resection

Assessment

A: Airway No airway devices used. Patient spontaneousely breathing.

D: Disability Drowsy patient, rousable to voice, but quickly falls alseep. Blood glucose 5.0 Complains of 6/10 abdominal pain when awake. Temperature: 36.5oC Pupils are Small ~2mm. Equal in size and reactive to light.

B: Breathing 5l/min Oxygen via facemask RR: 5 per minute SpO2 92% Clear chest on ascultation.

C: Cardiac HR: 88 BP: 121/76 CRT: <2s Seconds Warm & well perfused

Which single observation worries you the most?

Unit 1

A breathless bowel resection

What would you do next? Select the single best action to take.

Watch and wait Allow the patient more time to wake up, monitoring closely and reassessing regularly.

Escalate Increase oxygen flow rate and immediately alert the duty anaesthetist.

Pain Relief Administer 10mcg boluses of fentanyl and titrate to effect while monitoring pain scores.

Unit 1 Learning Objectives

This section is all about opoid toxicity

Understand the mechanism of action of opioid drugs

Understand the differences between commonly used opioids

Recognise the symptoms of opioid toxicity

Learn about the principles of management

Develop awareness of Naloxone and it's pitfalls

Unit 1

A breathless bowel resection

Opoids

• Opioids are opiates are commonly used group of analgesics in the theater environment.

• They are used to manage post-operative pain and are administered in the PACU environment
• Some patient may be on regular long-acting opiates prior to their operation
• Opoids/Opiates vary in their lenght of action, potency and side effect profile.

Opiate

Opioid

Opiates are drugs which are derrived from the opium plant (poppy). These are naturally occuring Opiates include Morphine, Codeine and Diamorphine (Heroin)

Opioids are drugs that resemble opiates. They are virtually identical in their actions. These are synthetically made Opioids include fentanyl, oxycodone, tramadol and methadone

VS

Unit 1

A breathless bowel resection

Mechanism of action

• Opioids are molecules which enter the body by various routes such as:
• Intravenous
• Oral
• Patches
• Intrathecal

• These molecules act on 3 receptor types which are found in the brain, spinal cord and gut. These receptors are:
• μ (mu)
• δ (delta)
• κ ( kappa).

• Activation of these receptors cause a complex cascade of intracellular signals which lead to various effects on the body

This table is greatly simplified and shows just some of the many effects activation of these receptors can have on the body.

Unit 1

A breathless bowel resection

Actions / Side effects

• Pain Relief
• This is the most common reason for administration of opiates

• Constipation
• Some opiates (such as Immodium/Loperamide) take advantage of this side effect to treat diarrhoea

• Respiratory Depression
• This is often considered to be a dangerous side effect, however, it can be a useful effect in managing breathlessness towards the end of life in palliative patients.

• Sedation
• Nausea
• Vomiting
• Itching
• Hypotension

• Euphoria
• Muscle rigidity
• Miosis (Constriction of pupils)
• Urine retention
• Cough Supression

• Dependency
• Seizures
• Bradycardia

Unit 1

A breathless bowel resection

Characteristics of commonly used opioids/opiates in PACU

Morphine

Oxycodone

Fentanyl

Onset of action 1-2 Minutes Peak Effect 10-30 Minutes Duration 3-4 Hours The longer duration of action of IV Morphine may be a useful property. There is a higher risk of accumulation in patients with reduced kidney function.

Onset of action 2-3 Minutes Peak Effect 5 Minutes Duration 4 Hours Oyxcodone has a rapid peak effect. It also has a longer duration of action, but its less likely to accmulate in patients with reduced kidney function.

Onset of action <1 min Peak effect 5 Minutes Duration 30-60 Minutes This is a very fast onset and relatively short duration drug. Large doses of fentanyl can accumulate in the body and have a duration measured in hours.

All of these drugs can build up in the body, especially in larger and repeated doses. The durations of action can be significantly longer.

Unit 1

A breathless bowel resection

Toxicity and its effect on breathing

• An excess of opioid drugs can cause significant respiratory effects. This is because opioids tend to affect the breathing centres within the brain and reduce the natural drive to breathe. This is called respiratory depression and can be seen as:
• A reduced rate of breathing (bradypnea)
• A reduced volume of air in each breath being taken (hypoventilation)
• Overall breathing may be insufficient.

• Insufficient breathing can lead to the accumulation of CO2 in the body
• This can lead to a patient becoming even more drowsy

• Insufficient breathing can lead to reduced oxygen levels (seen as reduced SpO2)
• This is called hypoxia and can be fatal if severe enough.

Unit 1

A breathless bowel resection

Clues in the history..

• It is important to consider which patients are at greater risk of respiratory opiate excess
• There were a number of clues in the handover of the case study that should have increased your index of suspicion of opiate excess.

Risk Factors

• Advanced age
• Kidney and liver failure
• Concurrent use of other medications with a sedative effect (such as after a GA)
• Obstructive sleep apnoea
• Preexisting respiratory disease (such as COPD)
• Preexisting cardiac disease (such as heart failure)

Let's revisit the case to highlight these features in the handover.

Unit 1

A breathless bowel resection

Handover

There are a number of features here which increase our risk of opiate excess. Place your cursor over the red circles to read more about why this is relevant.

A 74 year old man, with a history of hypertension, chronic kidney disease and ulcerative colitis has undergone an emergency laparotomy with a bowel resection for a bowel perforation, The surgery was uncomplicated. He was anaesthetised with a GA and endotracheal tube. He was extubated in theaters prior to transfer to the recovery area. Medications Administered: 15:00 Fentanyl 100mcg (on induction) 15:01 Propofol 200mg (on induction) 15:01 Rocuronium 90mg (on induction) 17:40 Paracetamol 1g 17:45 Ondansetron 5=4mg 18:00 Morphine 15mg 18:30 Sugammadex 200mg

Unit 1

A breathless bowel resection

Signs and Symptoms

• The assessment performed in the PACU area also highlighted a number of clues that may have pointed you towards an opiate excess.

Let's revisit the case to highlight these features in the patient assessment.

Unit 1

A breathless bowel resection

Place your cursor over the red circles to read more about why these findings in the assessment are relevant.

A: Airway No airway devices used. Patient spontaneousely breathing.

D: Disability Drowsy patient, rousable to voice, but quickly falls alseep. Blood glucose 5.0 Complains of 6/10 abdominal pain when awake. Temperature: 36.5oC Pupils are Small ~2mm. Equal in size and reactive to light.

B: Breathing 5l/min Oxygen via faemask RR: 5 per minute SpO2 92% Clear chest on ascultation.

C: Cardiac HR: 88 BP: 121/76 CRT: <2s Seconds Warm & well perfused

Unit 1

A breathless bowel resection

Management

Using the ABCD approach to the unwell patient in assessment highlighted a number of issues to address.

Support the airway

Improve breathing

Monitor cardiac

Stimulate patient

Prompt the patient to breathe. Give 15L/min O2 via a non rebreathe mask while awaiting an urgent review

There is a risk of arythmia and hypotension. Monitor closely with frequent BP checks and ECG monitoring.

Constant stimulation and prevention of falling asleep can help prevent airway obstruction and improve B

Drowsy patients may need a simple airway action such as a jaw thrust or chin lift to avoid obstruction

ESCALATION IS ESSENTIAL

Unit 1

A breathless bowel resection

ESCALATION IS ESSENTIAL

• Opiate excess leading to respiratory depression can be life-threatening if severe.
• A multi-disciplinary approach to the problem is essential

Concerning features that prompt a more urgent review include:

• Respiratory rate of <9
• Abnormal oxygen saturations for the patient's target (usually <94%)
• Persistent reduced responsiveness/drowsiness

The patient may require a reversal of their opiate medication

Unit 1

A breathless bowel resection

Naloxone

• Naloxone is a medication which can reduce or reverse the effects of opioids.
• When administered, it competes with opioids for the same receptors and prevents the opioid molecules from binding and producing their effect.
• It is commonly administered intravenously or intramuscularly.
• The IV route has a quicker onset and is preferred in patients with venous access.

Naloxone is usually presented in 400mcg/ml glass vials as a colourless liquid.

The BNF have produced dosing guidance for the use of Naloxone by medical practicioners. Doses vary for paediatric patients

More Info

Unit 1

A breathless bowel resection

Pitfalls with Naloxone

• Naloxone has a very rapid onset of action. It begins to work within 2 minutes of an intravenous injection and patients can be seen to have rapid improvements in their respiratory depression.
• It has a short duration of action, from 30 to 90 minutes.

As we have seen on previous pages, many opioid medications have a duration of action much longer than naloxone. Patients who have been given naloxone must therefore be monitored for longer to ensure respiratory depression does not reoccur after naloxone wears off. Sometimes naloxone infusions are needed for longer durations of treatment.

Unit 1

A breathless bowel resection

Key points

You have completed the learning portion of this unit.

Respiratory depression is an important side effect which can be life threatening if untreated

Opoid drugs are frequently used in the perioperative environment

An ABCD approach to assessment is useful to identify signs of opiate excess

They have a complex mechanism of action, affecting many body systems

Patients may require urgent escalation if they significant respiratory depression

There are various types of opioids which have different profiles for speed/duration

Naloxone plays a part in reversal of the effects of opioid medications

Opioids can accmulate in the body in patient with kidney or liver disease

Naloxone has a short duration of action and monitoring for a longer period of time is important.

Some patients are at greater risk of side effects such as respiratory depression

Unit 1

A breathless bowel resection

Check what you know

Go!

Unit 1

A breathless bowel resection

Which is these opioid medications have the shortest duration of action?

Morphine

Oxycodone

Fentanyl

Unit 1

A breathless bowel resection

Which is these is a concerning feature warranting urgent escalation?

Pupils which are 5mm

Heart rate of 95

Respiratory rate of 7

Unit 1

A breathless bowel resection

Which medication may be useful to reverse the effects of opioids?

Flumazenil

Naloxone

N-Acetyl Cysteine

Unit 1

A breathless bowel resection

What is the duration of action of naloxone?

3-4 Hours

30 - 90 Minutes

10-15 Minutes

Unit 1

A breathless bowel resection

Which is these medications is an opioid?

Codeine

Diclofennac

Paracetamol

Unit 1

A breathless bowel resection

Which of these is not an effect related to the use of opioids?

Cough supression

Hearing loss

Constipation

Unit 1

A breathless bowel resection

Which of these is a risk factor for respiratory depression when using IV Morphine?

Kidney Failure

Lung cancer

Diarrhoea

Unit 1

A breathless bowel resection

Unit 2 Unlocked.

You have completed Unit 1.

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Unit Menu

Unlocked!

Unit 1 A breathless bowel resection

Unit 2: An Itchy inguinal hernia repair

Unit 3 A sleepy shoulder replacement

Unit 4: A hypotensive hysterectomy

Unit 5: A noisy nephrostomy

Final Assessment

UNIT 2

An itchy inguinal hernia repair

Unit 2

An itchy inguinal hernia

A 54-year-old man, with a past medical history of hypertension, has undergone an elective repair of an inguinal hernia. The hernia was repaired with a mesh and the surgery was uncomplicated. The surgical team have prescribed antibiotics to be given in PACU to prevent infection. He was anaesthetised with a GA and a supraglottic airway device (I-gel). A nerve block was performed in theater prior to extubation and transfer to the recovery area. Medications Administered: 17:00 Fentanyl 100mcg (on induction) 17:02 Propofol 150mg (on induction) 17:10 Dexamethasone 6.6mg 18:10 Paracetamol 1g 18:15 Ondansetron 8mg 18:20 Levobupivacaine 100mg (Nerve block)

Unit 2

An itchy inguinal hernia

PACU Care

On transfer to the PACU area, the patient appears well. He is alert and free of pain. The observations are all within the normal range:HR 88 BP 121/78 RR 14 Temp 36.5oC Alert.

You administer the prescribed antibiotic and continue to monitor.

Unit 2

An itchy inguinal hernia

An unexpected deterioration..

Shortly after the patient reports feeling generally unwell. You notice the HR on the monitor is now 110. You hit the cycle button on the blood pressure monitor and perform a full assessment:

A: Airway No airway devices used. Patient spontaneousely breathing.

D: Disability Patient remains alert but continues to feel unwell. Now also reports feeling itchy and short of breath. Blood glucose 5.0 Temperature: 36.5oC Pupils are normal in size, equal, and reactive to light. Pain 3/10 over surgical site

B: Breathing 5l/min Oxygen via facemask RR: 25 per minute SpO2 94% Noisy breathing. Wheeze.

C: Cardiac HR: 120 BP: 90/48 Cool and clammy hands

Unit 2

Unit 2

An itchy inguinal hernia

An itchy inguinal hernia

What would you do next? Select the single best action to take.

Call the anaesthetist Bleep the theatre anaesthetist and ask for a medical review when possible

Call 2222 Put out a peri-arrest call to summon immediate medical help

Pain Relief Administer 10mcg boluses of fentanyl and titrate to effect while monitoring pain scores.

Unit 2 Learning Objectives

This section is all anaphylaxis

Understand the pathophysiology behind anaphylaxis

Recognise some of the common causative agents in the theater/PACU environment

Recognise the symptoms/signs of anaphylaxis

Learn about the principles of management

Develop awareness of the Resus Council guidelines

Unit 2

An itchy inguinal hernia

Anaphylaxis

The patient in the described case may be experiencing anaphylaxis. This is a life-threatening condition and urgent resuscitation is essential. Listen to this podcast from the Resus Council before moving on to the next section

Unit 2

An itchy inguinal hernia

What is anaphylaxis?

• Anaphylaxis is a

Bibliography

01

Magna Lorem. (1989). Lorem ipsum dolor sit (2.a ed., Vol. 3). Cordoba, SPAIN: Dolorelabore.www.loremipsumdolorsitamet.com/consecteteur/adisciping/1234.html

02

Magna Lorem. (1989). Lorem ipsum dolor sit (2.a ed., Vol. 3). Cordoba, SPAIN: Dolorelabore.www.loremipsumdolorsitamet.com/consecteteur/adisciping/1234.html

Magna Lorem. (1989). Lorem ipsum dolor sit (2.a ed., Vol. 3). Cordoba, SPAIN: Dolorelabore.www.loremipsumdolorsitamet.com/consecteteur/adisciping/1234.html

03

04

Magna Lorem. (1989). Lorem ipsum dolor sit (2.a ed., Vol. 3). Cordoba, SPAIN: Dolorelabore.www.loremipsumdolorsitamet.com/consecteteur/adisciping/1234.html

05

Magna Lorem. (1989). Lorem ipsum dolor sit (2.a ed., Vol. 3). Cordoba, SPAIN: Dolorelabore.www.loremipsumdolorsitamet.com/consecteteur/adisciping/1234.html

Magna Lorem. (1989). Lorem ipsum dolor sit (2.a ed., Vol. 3). Cordoba, SPAIN: Dolorelabore.www.loremipsumdolorsitamet.com/consecteteur/adisciping/1234.html

06

self appraisal

Lorem ipsum dolor sit amet consecteteur adisciping. An vim commodo dolorem volutpat, cu expetendis voluptatum usu, et mutat consul adversarium his.

Lorem ipsum dolor sit amet consecteteur adisciping. An vim commodo dolorem volutpat, cu expetendis voluptatum usu, et mutat consul adversarium his.

Lorem ipsum dolor sit amet consecteteur adisciping. An vim commodo dolorem volutpat, cu expetendis voluptatum usu, et mutat consul adversarium his.

Lorem ipsum dolor sit amet consecteteur adisciping. An vim commodo dolorem volutpat, cu expetendis voluptatum usu, et mutat consul adversarium his.

Lorem ipsum dolor sit amet consecteteur adisciping. An vim commodo dolorem volutpat, cu expetendis voluptatum usu, et mutat consul adversarium his.

Lorem ipsum dolor sit amet consecteteur adisciping. An vim commodo dolorem volutpat, cu expetendis voluptatum usu, et mutat consul adversarium his.

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Dr Rahim Esmail

Teaching Package Designer

Dr Rahim Esmail is a trust registrar in intensive care and anaesthetics.

Course feedback is always welcome:rahim.esmail@nhs.net

Dr Ronak Patel

Teaching Package Designer

Dr Ronak Patel is a Core Anaesthetics Trainee working in the Thames Valley Deanery.

Course feedback is always welcome:ronak.patel18@nhs.net

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Escalate

Correct answer.

This patient has a low respiratory rate and has an associated desaturation. The small pupils and large dose of morphine prior to the end of the procedure make opiate toxicity a possible cause. It would be important to provide more oxygen, including the use of a non re-breath mask at 15L/min. Summoning immediate medical help is essential as this patient may continue to rapidly deteriorate.

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Pain Relief

This is not the best option.

The patient has a dangerously low respiratory rate, and associated oxygen desaturation. While pain relief is very important, it is not the most important aspect of this patients care.

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Naloxone BNF Dose

Adult Initially 400 micrograms, then 800 micrograms for up to 2 doses at 1 minute intervals. If no response to preceding dose, then increased to 2 mg for 1 dose. If still no response (4 mg dose may be required in seriously poisoned patients), then review diagnosis; further doses may be required if respiratory function deteriorates following initial response, intravenous administration has more rapid onset of action, doses may be given by intramuscular route but only if intravenous route is not feasible.

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Dr Ronak Patel

Teaching Package Designer

Dr Ronak Patel is a Core Anaesthetics Trainee working in the Thames Valley Deanery.

Course feedback is always welcome:ronak.patel18@nhs.net

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Pain Relief

This is not the best option.

This patient is rapidly deteriorating. Pain management is important, but breathing and circulation concerns should be prioritised over this.

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Call the anaesthetist

This is not the best option.

It is reasonable to call the theatre anaesthetist - but in the face of rapid deterioration, putting out a peri-arrest call is likely a faster way to summon help.

Peri-arrest 2222

Correct answer.

This patient is hypotensive with a tachycardia and new breathing difficulty. The rapid onset is a concern and summoning immediate medical help would be the best response.There are important diagnoses which need to be explored as possible causes such as anaphylaxis, bleeding or even sepsis. It would be important to provide more oxygen, including the use of a non-re-breath mask at 15L/min.

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Watch and wait

This is not the best option.

This patient has a low respiratory rate and an associated decrease in oxygen saturation. Immediate action is required to address this.

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