CHAPTER 28. Perianesthesia Complications
Lois Schick
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
1. List three potential airway complications that may occur in the immediate postanesthesia period.
2. Describe the signs and symptoms associated with pulmonary edema.
3. Describe the signs, symptoms, and treatment of a patient with suspected pseudocholinesterase deficiency.
4. Identify two common causes of hypovolemia in the immediate postoperative setting.
5. Identify three risk factors that predispose a patient to postoperative nausea and vomiting (PONV).
I. PERIANESTHESIA SETTING
A. Patient complications can occur at any time
B. Critical communication
1. Safe transfer of care (Table 28-1)
a. Anesthesia provider, either an anesthesiologist or a Certified Registered Nurse Anesthetist
b. Special procedure unit reports to PACU nurse.
c. Surgery nurse conveys report to the PACU nurse.
| PACU, Post anesthesia care unit. | |||||
| Expected communications PACU nurse receives on patient admission | |||||
| COMMUNICATE | ASSESS | ||||
|---|---|---|---|---|---|
| Patient’s name and age | Airway patency | ||||
| Preoperative medical history | Breathing quality | ||||
| Anesthetic technique and duration | Cardiovascular stability | ||||
| INTRAOPERATIVE MEDICATIONS, TIMES, DOSES | DETERMINE AND MANAGE | ||||
| Sedatives, narcotics, relaxants | Consciousness | ||||
| Reversal medications | Pain | ||||
| Antibiotics, steroids, adjunctives | Muscle strength | ||||
| Fluid balance | Wounds and drains | ||||
| Critical procedural events | |||||
2. Written or computerized record
a. Convey patient’s stable progressive transition from sedation to wakefulness.
b. Inform all caregivers of:
(1) Events
(2) Complications
(3) Consultations
(4) Interventions
c. Complete, accurate, legible
C. PACU nurses
1. Assess continually the patient’s status.
2. Identify potential complications.
3. Treat untoward reactions.
II. CRITICAL POSTANESTHESIA ASSESSMENTS
A. Assessment priorities
1. Simultaneous overview of organ systems and responses during admission
a. Respiratory effort, oxygen saturation: artificial airway, intubated
b. Cardiac rate, rhythm, and vital signs: hypotensive, hypertensive, abnormal rhythm
c. Awareness, level of consciousness, and ability to move: arousable
d. Pain severity and anxiety: agitated or calm, implement pain scale
e. Residual effect of local anesthetic blocks, regional anesthetics
(1) Motor and sensory dermatome levels after spinal or epidural block
(2) Regional block renders extremity numb and difficult to control.
(a) Block effect provides wonderful pain management.
(b) Safety concern: protect from flailing, floppy extremity.
f. Thermoregulation: temperature and comfort
2. Determine need for 1:1 nursing care according to American Society of PeriAnesthesia Nurses (ASPAN) standards.
3. Repeat assessment at regular intervals according to standards and policies.
B. Surgery-specific observations
1. Integrity of dressings or visible suture lines, any drainage
2. Position, patency, and function of every monitoring line and wound drain
3. Abdominal girth, distention, nausea
4. Neurological and neurovascular status
a. Consciousness, respiratory effort, pupil size and equality, seizures, posturing, and movement after intracranial surgeries
(1) Stimulus required to elicit response
(a) Spontaneous?
(b) Touch or voice?
(c) Sternal rub?
(2) Degree and quality of response
(3) Improvement or decline during PACU observation
b. Capillary refill, sensation, motion, strength after spinal, orthopedic, peripheral vascular procedures
(1) Pulses, color, motion, sensation, temperature
(a) Shoulders to fingertips
(b) Hips to toes
(2) Doppler assessment if circulation or pulse quality questionable
(a) Cool or vasoconstricted extremity
(b) May be normally diminished if peripheral vascular disease
(3) Is any deficit new or present preprocedure worse or improved?
c. Impairment related to surgical position or events
(1) Vision impairment reported after hypotensive episodes
(2) Skin damage at pressure points: redness, blisters, breaks
(3) Peroneal nerve compression after legs in stirrups
(a) Numbness or tingling after urological, gynecological procedures
(4) Ulnar nerve stretch while areas extended and muscle relaxed
(a) Numbness
(b) Tingling
(c) Weakness
d. Impairment related to procedure
(1) Circulation distal to line site with:
(a) Intravenous (IV) infiltration
(b) Medication extravasation
(c) Arterial monitoring lines
(2) Edema or bleeding in surgical extremity can impair circulation.
(3) Tight casts, splints, and wraps can restrict venous return.
(4) Compartment syndrome
(a) Increased pressure in extremity’s fascial compartments
(b) Perfusion impaired: muscle and nerve ischemia result.
(c) Prompt pressure released lest tissue necrosis result.
(i) Surgical fasciotomy
(ii) Remove or split cast.
(iii) Monitor for hyperkalemia after muscle destroyed.
(d) Report immediately:
(i) Extreme pain unrelieved by narcotics
(ii) Paresthesia or paralysis
(iii) Pallor
(iv) Pulselessness of limb
5. Genitourinary status
a. Bladder distention: urge to void? Verify time of last void.
b. Catheter patency, urine color, clarity, volume, clots
c. Titrate flow of bladder irrigation systems.
d. Bladder ultrasound to assess bladder volumes
e. Determine necessity of urination before discharge.
(1) Consider increasing IV fluid rate to promote bladder volume.
(2) Instruct to strain urine for particles after lithotripsy.
6. Obtain, report, and review necessary x-rays, laboratory assessments.
a. Chest x-ray to verify placement of new central lines, endotracheal (ET) tube
b. Spinal or extremity x-rays per surgeon orders
c. Arterial blood gases if patient intubated and mechanically ventilated
d. Serum glucose in diabetics
e. Hemoglobin if significant blood loss during procedure
f. Electrolytes if extended surgery with multiple transfusions, extensive muscle destruction
C. Clearly document all assessments and events according to facility style and policy.
1. Observed deficits, physician consultations, orders
2. Outcomes of interventions
3. Times of each assessment, intervention
a. Increase frequency of assessments when deficit or compromise.
b. Every change in clinical status, improvement or decline
c. Airway removal, monitoring line insertion, laboratory and x-ray results
III. AIRWAY INTEGRITY (Box 28-1)
A. Complications heralded by:
1. Hypoxia: oxygen desaturation, decreasing partial pressure of oxygen (Pa o 2)—insufficient delivery
a. Arterial oxygen saturation (Sa o2) of 90% corresponds with partial pressure of oxygen in arterial blood (Pa o2) of 60 mm Hg.
b. Monitored oxyhemoglobin saturation <90%
c. Reduced respiratory rate, depth, effort
d. Oversedation: limited consciousness reduces stimulus to breathe.
e. Restlessness: still anesthetized patient may actually be disoriented, “air hunger.”
(1) May indicate return of narcotic or muscle relaxant effect
(2) Always ensure adequate oxygenation and ventilation before sedating.
(3) Only provide judicious, sparing analgesia until patient alert.
f. Cardiovascular status varies: hypertension to hypotension, dysrhythmias.
g. “High” spinal blockade
2. Hypercarbia: respiratory acidosis, increasing partial pressure of carbon dioxide (Pa co 2)
3. Factors that may increase airway risk
a. Anatomy: limit chest expansion, diaphragm, respiratory muscle movement.
(1) Obesity or pregnancy
(2) Neck: large and/or short neck
(3) Receding chin, “no” jaw
(4) Upper abdominal surgery
(5) History of obstructive sleep apnea
b. Poor muscle tone
(1) Medication effects
(a) Narcotics
(b) Muscle relaxants
(2) Neuromuscular diseases
(a) Myasthenia gravis
(b) Quadriplegia
c. Facial, throat swelling
(1) Anaphylaxis
(2) Surgical manipulation
(3) Edema
B. Obstruction: interrupted patency—an emergency in any PACU
1. Common when patient very sedated: airway reflexes blunted
a. Soft tissue obstruction: oropharynx blocked to air entry
(1) Slippage of tongue
(2) Foreign body (i.e., loose teeth)
b. Partial airway obstruction: snoring signals
(1) Reposition or elevate head.
(2) Turn patient to side-lying position.
(3) Jaw support
(4) Insert oral or nasal airway.
c. Total obstruction: rocking, asynchronous chest movements indicates:
(1) No chest expansion, no air entry audible with auscultation
(2) Flaring nostrils, tracheal tug, abdominal, accessory muscles
(3) Muscle relaxation or reintubation if jaw support ineffective
2. Risk
a. Hypoventilation or even apnea
b. Vomiting and aspiration
(1) Peptic ulcer
(2) Hiatal hernia
(3) Obesity
3. Nursing responsibility
a. Never leave the bedside of the sedated, inadequately breathing patient.
b. Be prepared.
(1) Sudden, silent vomiting
(2) Airway obstruction
(3) Apnea
(4) Wild disorientation
c. Ask a colleague to contact help or obtain supplies, medications.
d. Open airway.
(1) Turn patient to side.
(2) Mandibular extension or jaw thrust
(3) Insert artificial nasal or oral airway.
(4) Backward tilt of head
(5) Towel roll under shoulders
C. Laryngospasm and airway edema
1. Spasm of laryngeal muscles with partial or complete closure
a. Stridor: high-pitched, crowing respirations indicates partial obstruction.
b. Absent breath sounds indicates total obstruction.
2. Airway spasm precipitated by irritants or allergy
a. Blood, vomitus, mucus on vocal cord
(1) Suction well before extubation.
(2) Reduce stimulation of extubation.
(a) Remove ET tube or laryngeal mask airway (LMA) while deeply anesthetized.
(b) Wait until fully awake.
b. Smoking
c. Chronic obstructive pulmonary disease (COPD)
d. Airway irritability
e. History of asthma (bronchospasm)
f. Airway trauma
(1) Procedure: long or difficult intubation or LMA
(2) Never remove LMA while patient deeply sedated, unresponsive.
(3) Premature extubation or LMA removal predisposes patient to:
(a) Airway spasm plus aspiration
(b) Coughing
(c) Retching
(d) Obstruction
(4) Procedures
(a) Frequent suctioning
(b) Laryngoscopy
(c) Difficult intubation
g. Postintubation croup common among children
h. Coughing, upper respiratory infection
3. May be able to speak, indicating partial closure
a. Auscultate lungs for wheezes, air entry; monitor oximetry.
b. Constant nurse presence and assessment
c. Coach calmness, slow breathing; perhaps hyperextend head.
(1) Elevate head; provide humidified oxygen.
(2) Racemic epinephrine inhalations reduce swelling.
(3) Lidocaine to reduce irritability
(4) Decadron to reduce inflammation
(5) Edema symptoms may recur: observe several hours later.
d. Consult anesthesia provider, immediately if total obstruction.
(1) Provide 100% oxygen by positive pressure ventilation.
(2) Low (subparalytic) dose of succinylcholine to relax laryngeal muscles, then reintubate per anesthesia provider.
(3) Corticosteroids and/or lidocaine may be ordered to reduce airway irritation and swelling.
D. Bronchospasm
1. Event
a. Constriction of bronchial smooth muscle
b. Closure of small pulmonary airways
(1) Edema
(2) Increased secretions
c. Reaction caused by stimulating airway irritants
(1) Allergic response: airway and vascular response
(a) Occurs within 3 minutes after IV injection
(b) Sensitivity to:
(i) Medications
(ii) Chemicals
(iii) Latex
(2) Aspiration
(3) Intubation or endotracheal suctioning
d. Response more likely if preexisting COPD, asthma
2. Symptoms
a. Wheezing, often shallow, “noisy” respiration
b. Decreased oxygen saturation
c. Dyspnea
d. Intercostal retractions
e. Increased respiratory rate
3. Intervention
a. Increase oxygen delivery; consider humidified source.
b. Remove the irritant.
c. Therapy with inhaled aerosol of bronchodilator like albuterol or patient’s personal inhaler
d. Relax airway passages in severe responses.
(1) Muscle relaxants
(2) Lidocaine
(3) Epinephrine
(4) Hydrocortisone
E. Pulmonary edema: pink frothy sputum, dyspnea, wheezing, rales, hypoxia
1. Fluid accumulation in the alveoli causes:
a. Increase in hydrostatic pressure
(1) Fluid overload
(2) Left ventricular failure
(3) Mitral valve dysfunction
(4) Ischemic heart disease
b. Decrease in interstitial pressure
(1) Prolonged airway obstruction
c. Increase in capillary permeability
(1) Sepsis
(2) Aspiration
(3) Transfusion reaction
(4) Trauma
(5) Anaphylaxis
(6) Shock
(7) Disseminated intravascular coagulation
2. Noncardiac origin: sudden onset in young, healthy patients
a. Etiology: upper airway obstruction, rapid naloxone injection
(1) A strong patient’s effort to breathe against closed glottis
(2) Negative pressure increases within chest cavity.
(3) Sharp increase in hydrostatic pressure pulls water to lungs.
b. Symptoms
(1) Decreased lung compliance
(2) Chest x-ray findings
(a) Normal heart size
(b) No congestive heart failure
3. Cardiac origins: maximized cardiac compliance
a. Etiology
(1) Fluid overload
(2) Ischemic heart disease, cardiomyopathy
(3) Ventricular failure and/or cardiac valve dysfunction
(4) Increase in pulmonary capillary permeability
(a) Sepsis
(b) Critical multisystem illness
(c) Debilitation: cancer, liver failure
(5) Anaphylaxis or transfusion reaction
b. Symptoms
(1) Tachycardia
(2) Dyspnea
(3) Tachypnea
(4) Confusion
(5) Wheezing
(a) Rales
(b) Crackles
(6) Decreased blood pressure
(7) Paroxysmal nocturnal dyspnea
4. Intervention: treat cause.
a. Evaluate chest x-ray: pulmonary infiltrates
(1) Reintubation
(2) Mechanical ventilation to maintain oxygen
b. Morphine relaxes patient and pulmonary vasculature.
c. Diuretics if cardiac origin—not deemed useful if noncardiac
d. Monitor hemodynamics.
e. Reduce hypoxemia.
f. Upright sitting position
g. Oxygen administration
F. Pulmonary embolus: blood flow obstruction in pulmonary vessels
1. Likely causative factors in perianesthesia period
a. Thrombus as a result of perioperative venous stasis and immobility
b. Fat embolism after pelvic or long-bone fracture and/or surgery
c. Hypercoagulability conditions, dehydration, or damaged vessels
2. Symptoms and assessment
a. Acute onset of pleuritic chest pain
b. Tachypnea
c. Tachycardia
d. Agitation
e. Apprehension
f. Hemoptysis
g. Hypoxia
h. Hypotension likely
3. Intervention
a. Correct hypoxia, cardiovascular instability.
b. Prompt anticoagulation, initially with heparin
c. Prophylactic prevention
(1) Elastic hose
(2) Sequential compression sleeves/devices
(a) Foot
(b) Calf
G. Aspiration pneumonitis: prevention most prudent therapy
1. Always a potential, albeit rare complication among the sedated or anesthetized
2. Inhalation of gastric contents as a result of:
a. Full stomach: residual gastric volume, especially if particulate
b. Acidic gastric contents
c. Inability to protect airway: inhibited airway reflexes
d. Obesity
e. Pregnancy
f. Hiatal hernia
g. Diabetic: gastroparesis
h. Upper abdominal surgery. Laryngeal mask airway (LMA)
(1) Aspiration: an underreported complication
(2) If malpositioned, coughing, straining on LMA, risk is increased.
(3) Potential greater when placed by the inexperienced provider
i. Trauma patients
3. Inhalation of blood or foreign body
a. Loose teeth
b. Trauma during oropharyngeal manipulation or surgery
4. Assessment
a. Coughing, wheezing, hypoxia, hypercarbia, tachypnea
b. Bronchospasm or atelectasis, particularly if foreign body
c. Heart rate changes, dysrhythmias, hypotension
5. Interventions
a. Prevent by reducing risk.
(1) Ensure nothing by mouth (NPO) status of recommended duration.
(2) Side-lying position for sedated or obtunded patients
(3) Rapid sequence induction for at-risk patients
b. Chest x-ray to document infiltrates
c. Ensure airway patency; turn sedated patient to side.
d. Provide humidified oxygen; intubate if necessary.
e. Constant observation: never step away from bedside.
f. Count minute respiratory rate; observe depth.
g. Stimulate patient toward consciousness, deep breathing.
h. Frequently assess vital signs and act to maintain stability.
i. Continuously monitor oxygen saturation, even after PACU discharge.
j. Bronchoscopy if foreign body, large particles
k. Steroids controversial; antibiotic use only if indicated
l. Histamine antagonists
(1) Antacids
(2) Antiemetic therapy
(3) H 2 receptor blockers
(a) Cimetidine
(b) Ranitidine
(c) Famotidine
H. Hypoventilation: ineffective respiratory effort
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1. Results in:
a. Decreased oxygen saturation (P o 2), which may be first sign
b. Subdued respiratory rate, depth, effort
c. Obliterated airway protective gag and cough reflexes
d. Increased risk of pulmonary aspiration
e. Decreased level of consciousness: minimal responsiveness
f. Hypercarbia: increasing P co 2
(1) Compounds unresponsiveness
(2) Respiratory acidosis; if unresolved:
(a) Less responsiveness
(b) Cardiac dysrhythmia
(c) Unstable blood pressure
2. Contributing origins
a. Associated conditions
(1) Obesity
(2) Pregnancy
(3) Lengthy or upper abdominal surgeries/procedures
(4) Prolonged exposure to:
(a) Muscle relaxants
(b) Narcotic doses
b. Hemoglobin loss
(1) Reduces hemoglobin available to transport oxygen
(2) Consider low hemoglobin.
(a) Patient pale
(b) Oxygen saturation low
(c) Tachycardia
c. Renarcotization: residual narcotic or sedative effect
(1) Recurrence of extreme somnolence, poor ventilation
(2) Caused by gradual migration of narcotics and sedatives from tissues back into bloodstream
(3) Consider titrating a narcotic or benzodiazepine antagonist.
(a) Dramatically reverses narcotic effect
(b) Expect quick wakefulness, pain, agitation, tachycardia.
(c) Extend observation period at least 30 minutes.
(d) Opioid half-life is longer than single dose of antagonist.
d. Reparalysis or recurarization: protracted muscle weakness
(1) Neuromuscular blockade recreated
(2) Residual nondepolarizing muscle relaxants in tissue “outlive” effects of anticholinesterase (reversal) medications.
(3) Migrate into bloodstream and recreate weakness
(4) Muscles uncoordinated, weak, “floppy”
(5) Respirations shallow, gaspy; chest expansion minimal
(6) Awake patients panicked, anxious, restless
(7) Often pain despite weakness: no analgesia in muscle relaxants
(8) May need additional reversal doses, respiratory support, even temporary intubation
e. Pseudocholinesterase deficiency: genetic absence or lack
(1) Insufficient amount of the intrinsic enzyme needed to hydrolyze succinylcholine, the depolarizing muscle relaxant
(a) Normally breaks down within 3 to 5 minutes
(b) Affects 1 in 2500 to 1 in 2800 individuals
(c) Patient may be unaware of genetic predisposition until after receiving succinylcholine.
(2) Prolonged duration of succinylcholine effect in patients with abnormal or low levels of plasma cholinesterase
(a) Liver disease
(b) Malnutrition
(c) Severe anemia
(d) Pregnancy
(e) End-stage renal disease
(f) Acidosis
(3) Irreversible muscle weakness (“floppy”) and apnea
(4) Requires mechanical ventilation to support respiration
(a) Necessary until muscle strength gradually returns
(b) Psychological support, information, sedation
(5) Constant vigilance: patient alert, fearful, feels pain
(6) Educate patient and family to reveal before next anesthetic.
(7) Physician may recommend laboratory measure of dibucaine levels.
f. Pneumothorax: air entry into pleural space
(1) Acute chest pain, dyspnea, reduced or absent breath sounds in affected area from deflation of lung, lobe, or pleural bleb
(2) Caused by:
(a) Alveolar rupture from mechanical ventilation
(b) Surgical chest procedures that invade pleura
(c) Central line placement
(d) Complication of nerve blocks
(i) Interscalene
(ii) Intercostals
(iii) Brachial plexus
(3) Tension pneumothorax: after air entry into chest, intrapleural pressure increases and lung deflates; heart and great vessels pulled toward the intact lung.
(a) Hypoxia and inability to ventilate
(b) Decreased venous return
(c) Hypotension
(d) Tachycardia
(4) Monitor oxygenation.
(5) Elevate head of bed.
(6) Serial chest x-rays
(a) If <20% deflation, observe.
(b) If >20% or patient symptomatic, insert chest tube.
3. Care of intubated, perhaps ventilated patient
a. Verify effective placement of ET tube.
(1) Auscultate breath sounds.
(a) Bilateral air entry all lobes
(b) Clear sounds without rhonchi
(c) Chest x-ray as indicated
(2) Continuous monitoring of oxygen saturation with pulse oximetry
(3) Sample arterial blood gases.
(a) Basis to assess adequacy of ventilator settings
(b) Determine acidosis.
b. Periodically suction via ET tube to clear secretions using sterile technique.
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