2 hours ago Hypotension is a common postoperative complication in the perianesthesia setting and contributes to increased patient morbidity and mortality rates. An understanding of the etiologies, diagnosis, and treatment of this complication is critical to successful treatment of the patient. This article presents an algorithm designed to provide the perianesthesia nurse with a step-by … >> Go To The Portal
Intraoperative hypertension or hypotension is associated with a higher rate of PACU complications, and patients who undergo general anesthesia have a higher rate of complications than patients who receive regional anesthesia. Critical respiratory events after general anesthesia have a reported rate of 1.3%. 4 Figure. No caption available.
Full Answer
Hypotension in the PACU: An algorithmic approach. Abstract. Hypotension is a common postoperative complication in the perianesthesia setting and contributes to increased patient morbidity and mortality rates. An understanding of the etiologies, diagnosis, and treatment of this complication is critical to successful treatment of the patient.
General medical supervision and coordination of patient care in the PACU should be the responsibility of an anesthesiologist. There shall be a policy to assure the availability in the facility of a physician capable of managing complications and providing cardiopulmonary resuscitation for patients in the PACU.
Whenever feasible, the anesthesia resident should be present at the time of arrival of the patient into the PACU, should receive a verbal report about the patient and should review relevant records, including the anesthesia record. The PACU rotation should emphasize immediate post-anesthesia and postoperative care issues.
THE PATIENT SHALL BE CONTINUALLY EVALUATED AND TREATED DURING TRANSPORT WITH MONITORING AND SUPPORT APPROPRIATE TO THE PATIENT’S CONDITION. UPON ARRIVAL IN THE PACU, THE PATIENT SHALL BE RE-EVALUATED AND A VERBAL REPORT PROVIDED TO THE RESPONSIBLE PACU NURSE BY THE MEMBER OF THE ANESTHESIA CARE TEAM WHO ACCOMPANIES THE PATIENT.
High Blood Pressure (Hypertension) Medications If general anesthesia is planned for your surgery this can interact with some types of blood pressure medications. If you take one of these medications on your day of surgery, your blood pressure could get dangerously low.
Ephedrine and phenylephrine Ephedrine is the first-line treatment of intraoperative hypotension during general anesthesia.
Treating low blood pressure during surgery may decrease risk of developing postoperative delirium. Newswise — SAN DIEGO – Patients who experience low blood pressure during surgery are at increased risk for postoperative delirium, according to a large study being presented at the ANESTHESIOLOGY® 2021 annual meeting.
Treatment of hypotension may include decreasing anesthetic depth and administering intravenous crystal- loid and colloid fluids, anticholinergic agents (as positive chronotropes), and positive inotropic agents to improve contractility.
Fludrocortisone is recommended as first-line drug therapy.
Agents that can be used alone or in combination include calcium channel antagonists (e.g. nicardipine), beta-adrenoceptor antagonists (beta-blockers) [e.g. propranolol, esmolol] and fenoldopam. Agents that are mainly used adjunctively include ACE inhibitors and clonidine.
The authors believe, however, that the most common cause of postoperative hypotension is that group of hematological factors which include transfusion reactions, hemolysis due to distilled water during transurethral resections, and acute or chronic loss of blood.
As Dr. Cohen reported at the 2018 annual meeting of the American Society of Anesthesiologists (abstract A1070), postoperative hypotension was found to be a common occurrence, with 24% of patients experiencing at least one episode of MAP less than 70 mm Hg lasting at least 30 minutes.
It alters cardiac electrophysiological function and may cause arrhythmia and decrease cardiac contractility [1], [2]. Furthermore, isoflurane decreases peripheral vascular resistance [3], leading to hypotension.
Figure 4: Clinically meaningful hypotension (systolic pressure <90 and prompting intervention). In total, 2,860 of 14,687 patients (19.5%) experienced at least one episode of clinically meaningful hypotension after their surgery; 2,728 (95.4%) of those patients experienced a hypotensive episode by postoperative day (POD) 3. OR = operating room; PACU = postanesthesia care unit. 22
Intraoperative hypotension is associated with MINS and MI, with the harm threshold being a mean arterial pressure (MAP) ≈65 mmHg (Figure 2). 18,19 Postoperative hypotension is also associated with myocardial infarction, independent of intraoperative hypotension (Figure 3). 20,21
4 The two most common and comparable causes of 30-day mortality after noncardiac surgery are major bleeding and myocardial injury. 5,6
Vasopressors like phenylephrine or norepinephrine are commonly used to treat hypotension during surgery. Phenylephrine is by far the most commonly used pressor in the United States, 65 whereas norepinephrine is generally preferred elsewhere. Phenylephrine is a pure alpha agonist which raises blood pressure by increasing systemic vascular resistance, usually with a compensatory decrease in cardiac output. 66 In contrast, norepinephrine combines powerful a-adrenergic agonism with weak b-adrenergic agonist activity which helps maintain cardiac output. Consequently, while blood pressure is comparably maintained with each vasopressor, 67 phenylephrine reduces splanchnic blood flow and oxygen delivery. 68 Clinicians should avoid phenylephrine in patients with septic shock. 69
General hospital floor hypotension is common, prolonged, and profound. It is likely that most perioperative hypotensive organ injury occurs postoperative rather than intraoperatively. The challenge is that blood pressure is usually measured intermittently. Even at 4-hour intervals, about half of all potentially serious hypotensive episodes are missed. 73 (Most hypoxemia is similarly missed with intermittent ward monitoring. 30) Reliably detecting and treating ward hypotension will require continuous vital sign monitoring. But in the meantime, avoiding angiotensin converting enzyme inhibitors and angiotensin receptor blocks on the day of surgery helps, 22 as does restarting chronic antihypertensive medications only when clearly needed.
Intraoperative hypotension cannot be reliably predicted from baseline patient characteristics or the surgical procedure. 58 How best to prevent and treat perioperative hypotension remains unclear. There is remarkably little correlation between intraoperative cardiac index and blood pressure, and the assumption that maintaining adequate vascular volume prevents hypotension does not appear accurate. Furthermore, in one study, a third of all intraoperative hypotension occurred between anesthetic induction and surgical incision—and was thus obviously consequent to anesthetic drugs rather than volume shifts. Pre-incisional hypotension is as strongly associated with organ injury as subsequent hypotension. 59
29 General hospital floor hypoxemia is common, profound, and prolonged 30; however, it remains unknown whether hypoxemia contributes to myocardial injury. Fortunately, simultaneous hospital floor hypotension and hypoxemia—which might especially provoke supply-demand injury—is rare.
The function of the circulation is to maintain flow of blood though tissue capillaries, delivering oxygen and may other substances to the surrounding tissues, as well as removing waste products and products of metabolism from these tissues.
Hypotension in non-septic, and non-hypothermic persons can be divided into two basic groups.
The preceding paragraphs reveal that hypotension does not have the same pathophysiology. However this discussion does not provide any usable practical information to guide the practical anesthesiologist.
General anesthesia generally reduces the cerebral oxygen consumption. This explains why so many people fail to manifest any cerebral damage resulting from the inadvertently profound episodes of hypotension occasionally accompanying induction of anesthesia.
We cannot measure cerebral blood flow during anesthesia, so blood pressure, supplemented with cerebral monitors such as the BIS monitor, is all that is possible to measure the adequacy of cerebral blood flow.
Similar consideration should be given to factors that may adversely affect vascular resistance. Several factors that may lead to decreased vascular resistance and cause hypotension are medication related. A patient who remains in a state of deep anesthesia may be vasodilated from the effects of the anesthetic and unable to compensate, resulting in hypotension. A patient with a high or profound regional blockade (usually spinal, but also may occur with epidural anesthesia) may have high levels of sympathectomy sufficient to cause hypotension. In these cases, the hypotension should be treated with vasopressors (such as ephedrine or phenylephrine) until the local anesthetic effect resolves.
As with any acute patient problem, assessment and treatment of postoperative hypotension should begin with rapid assessment of the patient's sensorium and level of consciousness (LOC), as well as airway, breathing, and circulation (ABCs). In the presence of hypotension, a patient with a decreased LOC or altered sensorium may be showing relatively late signs of end organ hypoxia, necessitating rapid and effective treatment.
The hypotension algorithm is designed to provide the perianesthesia nurse with a step-by-step guide to the assessment and management of the perianesthesia patient presenting with hypotension (Fig 1).#N#Download : Download high-res image (52KB)#N#Download : Download full-size image#N#Fig. 1. The hypotension algorithm.#N#Assessment priorities are outlined, and intervention strategies are discussed.
Hypotension is a common postoperative complication in the perianesthesia setting and contribute s to increased patient morbidity and mortality rates. An understanding of the etiologies, diagnosis, and treatment of this complication is critical to successful treatment of the patient. This article presents an algorithm designed to provide the perianesthesia nurse with a step-by-step guide to the assessment and management of the patient presenting with hypotension. © 2002 by American Society of PeriAnesthesia Nurses.
So what should be done with a hypotensive patient who may be hypovolemic, but has not definitely been diagnosed as such? In the absence of specific contraindications (such as congestive heart failure), a fluid challenge of 0.9% saline solution is indicated. If the patient responds to a fluid bolus by becoming less hypotensive, then hypovolemia generally may be assumed. Additional fluid boluses may be necessary to return the patient to normovolemia and alleviate hypotension.
The most common cause of hypotension is hypovolemia, defined as a direct reduction of flow (circulating volume). The relationship of circulatory function to blood pressure can be described by Ohm's law, where flow (circulation) is directly proportional to change in pressure, and inversely proportional to resistance (degree of vasoconstriction): Hypovolemia therefore will reduce blood pressure in direct proportion to the extent that homeostatic mechanisms leading to vasoconstriction (increased resistance) cannot compensate.
The causes of hypotension in the perianesthesia setting are diverse and, at times, difficult to diagnose. An algorithmic approach assists the perianesthesia nurse in determining the causes of hypotension in the perianesthesia patient. With such an approach, perianesthesia nurses may treat hypotension more quickly and effectively, resulting in improved patient outcomes.
The third step of preparing the PACU Handoff Checklist was to measure its effectiveness during actual PACU handoffs. We randomly observed 10 PACU handoffs and screened for additional items exchanged that should be included in our handoff checklist. We found that “preoperative vital signs” and “other medications (antihypertensives and steroids)” were an integral part of the handoffs process but were not included in previous lists.
As a quality improvement initiative, our institution has focused on the anesthesia team-to-PACU nurse handoff. The ASA defines the standard for OR-to-PACU handoff: “Upon arrival in the PACU, the patient shall be re-evaluated and a verbal report to the responsible PACU nurse by a member of the anesthesia care team who accompanies the patient.” 3 In spite of these guidelines, the quality and quantity of information exchanged can still be variable. Some institutions have adopted standardized handoffs, such as SBAR (situation, background, assessment, recommendation) to try to ensure a quality exchange of information. However, no large scale studies have indicated the best structured approach and no widely accepted guidelines exist for PACU handoff. 4
Items most commonly missed include Preoperative Cognitive Function, Lines/catheters, and Antiemetics. Missed items may have been excluded for 2 reasons. The resident may have deemed a particular item non-essential to the transition of care or may have missed the item due to general unfamiliarity with the new tool. In the latter case, further use of the checklist would likely lead to an additional increase in amount of information included in the PACU handoff.
While they included significantly more items in their handoff, residents who used the PACU Handoff Checklist spent a significantly longer amount of time completing their handoff compared to those that did not use a checklist (Group B: 126.4 +/- 52.25 seconds; Group A: 100.86 +/- 36.00 seconds, p = 0.011).
Data collectors were volunteer medical students who were independent from the care team and study team. They observed the handoff without intervention and made no assessment of the quality of the information exchanged. A stopwatch was used to record the time from the start to finish of the sign out. All times were rounded to the nearest second.
Items most commonly missed include Preoperative Cognitive Function, Lines/catheters, and Antiemetics. Missed items may have been excluded for 2 reasons. The resident may have deemed a particular item non-essential to the transition of care or may have missed the item due to general unfamiliarity with the new tool.
Anesthesia providers participate in patient handoffs several times for each patient under their care. Each handoff has the potential for poor communication that may jeopardize patient safety.
In the absence of the physician responsible for the discharge, the PACU nurse shall determine that the patient meets the discharge criteria. The name of the physician accepting responsibility for discharge shall be noted on the record.
Standards for Postanesthesia Care. These standards apply to postanesthesia care in all locations. These standards may be exceeded based on the judgment of the responsible anesthesiologist. They are intended to encourage quality patient care, but cannot guarantee any specific patient outcome.
The anesthesiology resident, under appropriate supervision must determine if patients fulfill PACU discharge criteria and confirm that the transfer will be to a hospital unit with appropriate resources and staff to provide necessary postoperative care. At the time of discharge from PACU, the resident should communicate significant postoperative events and/or concerns to the providers assuming care for the patient.
Resident responsibilities may also include participation in emergency resuscitation and other emergency care within the hospital and participation in a rapid response team.
Most patients undergoing anesthesia and surgery will be transferred to Post Anesthesia Care Unit (PACU) for immediate postoperative management. In order to gain experience in the immediate postoperative care of surgical patients, each anesthesia resident should have a formal rotation in the PACU. During this rotation, anesthesiology residents will be assigned to the PACU and must directly manage postoperative patients, with emphasis on pain management, hemodynamic evaluation and management, airway emergencies that occur during the PACU stay and other clinical situations that arise in the immediate postoperative period. Whenever feasible, the anesthesia resident should be present at the time of arrival of the patient into the PACU, should receive a verbal report about the patient and should review relevant records, including the anesthesia record.#N#The PACU rotation should emphasize immediate post-anesthesia and postoperative care issues. Resident responsibilities may also include participation in emergency resuscitation and other emergency care within the hospital and participation in a rapid response team. These additional responsibilities should not compromise patient care within the PACU.#N#The PACU rotation should include didactic lectures and case discussions related to immediate postoperative care needs, clinical assessment and patient management. Residents should gain an understanding about postoperative care needs and resource utilization, patient triage and bed allocation.#N#Appropriate supervision should be provided by faculty knowledgeable about postoperative management who are available for assistance and/or consultation at any time.
The resident should develop skills at communication of patient needs and coordination of care between the medical staff, nursing staff and other providers. Appropriate medical records shall be kept during the PACU period.
The anesthesiology resident should participate in the transition of care from various anesthetizing locations to inpatient settings and home care. As part of the postoperative experience, all residents must develop the skills to assess patient needs, identify the most appropriate site for further postoperative care, and ensure safe and timely transfers of care to other providers. The resident should develop skills at communication of patient needs and coordination of care between the medical staff, nursing staff and other providers. Appropriate medical records shall be kept during the PACU period.
These instruments include the Aldrete, Modified Aldrete (also known as PARSAP), Post Anesthetic Discharge Scoring System (PADSS), and White scoring systems. 20 (See Examples of scoring systems .)
In postanesthesia phase II, the focus of care is to prepare the patient for discharge to either an extended-care environment or home with supervision and postanesthe sia instructions. 4,5 The extended-care environment includes a medical-surgical unit, or an ICU.
The PACU nurse must recognize the risk to patients when they are prematurely discharged from PACU care. Ensuring that patients have an appropriate level of consciousness, have stable vital signs, can protect their airway, and have objective signs of stable oxygen saturation is key to safely discharging the patient to another setting. By following these guidelines, the PACU nurse can promote a decrease in complications and provide safe, high-quality care that leads to a timely discharge to the appropriate care environment. 2,5,10,11 Following a structured, systematic guideline process for PACU discharge provides the nurse with the highest strength and quality of evidence available to guide the interprofessional surgical team with effective evidence to support PACU discharge and help the patient avoid undue PACU delays. 8,11,13
Postanesthesia nausea and vomiting (PONV) are common occurrences associated with some types of anesthetic agents, surgery, or opioids used for pain management. Adequate antiemetic prophylaxis and regimens improve patient comfort, readiness for discharge, and care satisfaction. 2,11 PONV should be controlled, and a pharmacologic regimen should be in place. 5 PACU nurses can use a more objective tool, such as the VAS or the verbal descriptor scale, to better assess PONV status in preparation for discharge. The verbal descriptor scale helps identify the severity of the nausea as none, mild, moderate, or severe, whereas the VAS is a scale with standard 100-mm line marked with “no nausea” at the left end and “worst nausea” at the right end. 2,18
Pain management. Pain management is also a very important discharge deterrent. Evidence from one study suggests that ineffective pain management can delay PACU discharge and negatively impact patient outcomes. 4 Postanesthesia pain must be treated and controlled with adequate oral or I.V. medication and/or other multimodal analgesic options (such as patient-controlled analgesia, epidural analgesia, patient-controlled epidural analgesia, or nerve block). 11,15,16 Effective pain management is assessed as a pain score reported by the patient as at least tolerable and adequately controlled while at rest. 5,17 When using other necessary tools, the nurse should follow the PACU policy assessment guidelines to ascertain if the patient meets the criteria for a safe discharge. One of the most commonly used tools with patients in the PACU is the patient verbally stating the severity of his or her pain from 0 to 10 (0 conveying “no pain” to 10 conveying the “worst pain”). The Visual Analog Scale (VAS), presented as a 100-mm horizontal line with the left end representing “no pain at all” and the right end representing the “worst pain,” is also commonly used. 18
The PACU nurse and interprofessional surgical team's aim is to transition the patient from postanesthesia phase I to postanesthesia phase II. 4 The PACU nurse's focus during postanesthesia phase I is on receiving the patient from the OR and providing continuous and basic life-sustaining care. 4 Vigilant care in this phase assists in enhancing recovery from anesthesia and restoring vital signs to near baseline measurements. This care is essential for the patient to transition to phase II.
To achieve optimal patient outcomes, nurses need to be familiar with evidence-based practices surrounding safe patient discharge from the postanesthesia care unit. Nurses can improve interprofessional surgical team communication by properly and thoroughly documenting criteria-based postanesthesia patient assessments.
Acute elevations in blood pressure (>20%) in the intraoperative period are typically considered hypertensive emergencies ( Goldberg and Larijani 1998 ). Postoperative hypertension (arbitrarily defined as systolic BP ≥190 mm Hg and/or diastolic BP 100 mm Hg on 2 consecutive readings following surgery) ( Plets 1989; Chobanian et al 2003b) may have significant adverse sequelae in both cardiac and noncardiac patients. Hypertension, and hypertensive crises, are very common in the early postoperative period and are related to increased sympathetic tone and vascular resistance ( Roberts et al 1977; Alper and Calhoun 2002 ). Postoperative hypertension often begins ~10–20 minutes after surgery and may last up to 4 hours ( Towne and Bernhard 1980 ). If left untreated, patients are at increased risk for bleeding, cerebrovascular events, and myocardial infarctions ( Goldberg and Larijani 1998 ).
Because many patients that develop postoperative hypertension do so as a result of withdrawal of their long-term antihypertensive regimen, this withdrawal should be minimized in the postoperative period. One preventive approach is to substitute long-acting preparations of the patient’s long-term antihypertensive regimen starting, if possible, several days before surgery and to be given in the morning of the day of surgery.
The ideal agent for treatment of hypertensive emergencies should be rapid acting, predictable and easily titrated, safe, inexpensive, and convenient. Currently, many options are available ( Table 1 ), each with distinct advantages and disadvantages. Preferred agents include labetalol, esmolol , nicardipine, and fenoldopam. Since an immediate reduction in blood pressure is desired, parenteral agents are discussed, with emphasis placed on newer agents. Clonidine and ACE inhibitors are long acting and poorly titratable; however, these agents may be useful in the management of hypertensive urgencies. ACE inhibitors are contraindicated in pregnancy ( DiPette et al 1985; Hirschl et al 1997 ). A review of agents used in the management of perioperative hypertension, preferred conditions, and dosing is presented in Table 2.
Fenoldopam is a peripheral dopamine-1 (DA) receptor agonist administered by IV infusion for the treatment of severe hypertension. Fenoldopam is unique among the parenteral BP agents because it mediates peripheral vasodilation by acting on peripheral dopamine-1 receptors. Fenoldopam is rapidly and extensively metabolized by conjugation in the liver, without participation of cytochrome P-450 enzymes. Fenoldopam has been associated with an increase in urine output and occasionally an increase in creatinine clearance ( White and Halley 1989; Elliott et al 1990; Shusterman et al 1993) which makes fenoldopam use appealing in perioperative patients with or at risk for renal dysfunction.
When emergent surgery is necessary, excessive BP elevations should be lowered to limit or prevent possible aggravation of bleeding and damage to vital organs . Assuming there is no immediate threat to vital organ function, as may occur in patients with end organ disease secondary to chronic hypertension, such perioperative elevations in BP can generally be considered hypertensive urgencies ( Mann and Atlas 1995 ).
In patients with a hypertensive emergency, it usually is necessary to treat with a parenteral antihypertensive agent. In the acute setting, the treatment goal is to decrease blood pressure by no more than 25% ( Chobanian et al 2003a ). Advancing these guidelines, the authors believe the immediate goal of therapy in hypertensive emergencies to reduce diastolic BP by 10% to 15%, or to approximately 110 mm Hg, over a period of 30 to 60 minutes. Sodium and volume depletion can be significant, and gentle volume expansion with IV saline solution will serve to restore organ perfusion and prevent an abrupt decline in BP when antihypertensive regimens are initiated. This goal decreases the likelihood of too-aggressive control, which may result in target organ hypoperfusion. Patients with chronic hypertension have cerebral and renal perfusion autoregulation shifted to a higher range. The brain and kidneys are particularly prone to hypoperfusion if blood pressure is lowered too rapidly. With the threat of organ injury diminished, attempts should be made to control blood pressure to baseline levels during 24 to 48 hours.
The Sixth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC6) ( Chobanian et al 2003a; JNC 1997) identifies patients with a systolic blood pressure (BP) of >180 mm Hg, or a diastolic that is >110 mm Hg, as having a “hypertensive crisis”. Hypertensive crisis is a term referring to either hypertensive emergencies or urgencies.