60 CriticalCareNurse Vol 30, No. 1, FEBRUARY 2010 www.ccnonline.org

Ask the Experts

Roberta Kaplow is a clinical nurse specialistat Emory University Hospital in Atlanta,Georgia.

After administration, the recov-ery process of neuromuscular block-ing agents is from larger to smallermuscle groups.1 As neuromuscularblocking agents do not possess anal-gesic or amnestic properties, appro-priate medications must be provided.

If nurses are caring for patientswho received spinal anesthesia, sen-sory and motor assessments are madeevery 15 minutes for return of func-tion. A dermatome diagram is used toassess sensory function. Motor block-ade is assessed via attempts to movethe lower extremity. Patients whoreceived spinal anesthesia must alsobe evaluated for the presence of com-plications, including hypotension,bradycardia, nausea and vomiting,and spinal headache. Hypotension istreated with fluid replacement, vaso-pressors, or both. Bradycardia istreated with atropine or fluid replace-ment. Nausea and vomiting are typi-cally due to hypotension and aremanaged with fluid replacement andpossibly with antiemetics. Spinalheadache is due to leakage of cere-brospinal fluid from puncture of thedura. If treatment with analgesicsand hydration is not effective andthe headache is severe, an epiduralblood patch may be required.1

As with any ICU admission,patients are immediately attached toappropriate monitoring equipment.Hand-off communication includesdiscussion of the procedure per-formed, baseline status and history,

anesthetic agent reachesthe tissues by the blood-stream, the more blood-rich tissue receives moreof the anesthetic agent. Assome inhalation agentsare also fat soluble, theyare absorbed in adipose

tissue. Adipose tissue is not veryvascular, so overweight patientshave a prolonged recovery frominhalation agents.1

To help anticipate postoperativehemodynamics, ICU nurses shouldappreciate the effects of the agentsused most often. Examples of sucheffects include tachycardia (fromenflurane or isoflurane), hypoten-sion (from enflurane, sevoflurane,and desflurane), decreased cardiacoutput (from desflurane), anddecreased systemic vascular resist-ance (from enflurane or sevoflurane).Enflurane and halothane sensitizethe heart to catecholamines.

Inhalation agents are eliminatedfrom the body through respirationand are respiratory depressants, sonursing care of recovering patientsincludes administration of oxygenand deep breathing and monitoringfor respiratory depression. Nursingcare also entails monitoring vitalsigns for cardiovascular effects, pre-venting or treating postoperativenausea and vomiting, and pain man-agement because inhalation anes-thetics (except for nitrous oxide) haveno analgesic properties.1

Author

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Care of Postanesthesia Patients

QQWhat do nurses in inten-sive care units need toknow about the care of

patients after anesthesia?

©2010 American Association of Critical-Care Nurses doi: 10.4037/ccn2010386

ARoberta Kaplow, RN, PhD,

CCNS, CCRN, AOCNS, replies:

Based on the physician’s pref-erence or the intraoperative course,patients may be admitted directlyfrom the operating room to the inten-sive care unit (ICU). Therefore, ICUnurses must be familiar with stan-dards of care for patients in theimmediate postoperative period,anesthetic agents, and managementof potential complications. Allpatients admitted directly from theoperating room must have stan-dards of postoperative monitoringmaintained. Constant surveillanceis required.1

Cardiac output affects the degreeto which an inhalation agent movesfrom alveoli to arterial blood. As the

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surgery length and type, significantintraoperative events, and intakeand output including estimatedblood loss.1

Once the patient is being moni-tored, a comprehensive assessmentis performed. All relevant assessmentdata are collected, as defined by crit-ical care nursing standards. Vitalsigns are recorded every 5 minutesfor 20 minutes and then every 15minutes and as needed. Surgery-specific data are also collected.

Once clinically indicated, thepatient is assessed for signs of readi-ness for weaning from mechanicalventilation. Typical parameters plussustained head lift of greater than 5seconds and strong hand grips areconsidered.

Patients who underwent generalanesthesia must receive humidifiedoxygen, usually via nasal cannula,until they are able to maintain anoxygen saturation shown by pulseoximetry of at least 93%. Patients whoreceived an inhalation agent requirethe “stir-up regime.” Patients need tobe “stirred-up” by elevating the headof the bed, unless contraindicated,and encouraging the patient tobreathe deeply at frequent intervals.This facilitates gas exchange by mov-ing the inhalation agent from higherconcentration (patient’s lungs) tolower concentration (environment).1

Thermoregulation is essential.Hypothermia (defined as body tem-perature <36˚C [96.8˚F]) has severalpotentially adverse effects, includingvasoconstriction, increased afterload,increased oxygen demand, or throm-bus formation; angina or myocardialinfarction; decreased platelet func-tion, cardiac output, or heart rate;and dysrhythmias. Shivering causesincreased oxygen demand, bleeding

times, blood viscosity, and risk formetabolic acidosis, along with hyper-ventilation and hypoxia. Activerewarming is required.2 Body tem-perature should be assessed uponICU admission and at the end of thepostanesthesia period.

A patient may be dischargedfrom anesthesia’s care when physio-logical criteria are met. These criteriamay include airway patency, oxygensaturation, vital signs, level of con-sciousness, muscle strength, and paincontrol. A scoring system, such asthe Aldrete Scoring System, can beused to evaluate the effect of sedationon the patient’s neurological, circu-latory, and respiratory systems. Thissystem uses a grading system from0 to 2 for level of activity, level ofconsciousness, respiratory ability,blood pressure, and color. The mod-ified Aldrete Scoring System evalu-ates oxygen saturation as shown bypulse oximetry instead of color. Thepatient must score 8 or higher orreach their baseline to be consideredrecovered from anesthesia.1

As with other ICU admissions,while a patient is recovering, it isessential for the patient’s family tobe updated on the patient’s status.Nurse communication with thepatient’s family at regular intervalsis pivotal. Visitation is recommended.

The ICU nurse must be familiarwith common complications of theimmediate postoperative periodand their management. Hypoventi-lation and hypoxemia are 2 of themost frequently reported complica-tions. These are typically related tothe anesthetic agents administered.Timely recognition of the problem bypulse oximetry and end-tidal carbondioxide monitoring and assessmentof the patient are essential. Treatment

varies depending on the cause ofthe problem.

Laryngospasm, commonlyrelated to intubation, aspiration, orsuctioning, may occur at any time.The patient should be encouragedto cough, as coughing may be allthat is required to break a partialobstruction. Other treatmentsinclude positive pressure ventila-tion with a bag-valve-mask. If alaryngospasm does not respond topositive pressure ventilation within1 minute, the patient is typicallytreated with administration of ashort-acting neuromuscular block-ing agent and reintubation.1

Noncardiogenic pulmonaryedema may occur as a consequenceof an acute upper airway obstruc-tion. Protein and fluid accumulatein alveoli with no elevation in pul-monary artery occlusive pressure.Signs and symptoms include tachyp-nea, tachycardia, decreased oxygensaturation, crackles, and frothy spu-tum. Treatment includes supple-mental oxygen, respiratory support,and diuretics.1

Hypotension is common in theimmediate postoperative period. Ittypically is caused by hypovolemiafrom fluid losses during surgery.Other causes may include cardiacdysfunction, low systemic vascularresistance, dysrhythmias, or hypox-emia. As with other critically illpatients, initial treatment includesadministration of isotonic fluidboluses and reversing the underly-ing cause. Administration of bloodproducts, inotropes, or vasocon-strictors may also be necessary. Thepatient may be placed in modifiedTrendelenburg position (flat withlegs elevated) to improve cardiacoutput and increase blood pressure.

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References1. Dozier T. Care of the postoperative patient.

In: Kaplow R, Hardin SR, eds. Critical CareNursing: Synergy for Optimal Outcomes. Sud-bury, MA: Jones & Bartlett; 2007: 651-666.

2. American Society of PeriAnesthesia Nurses.Resource 12: American Society of PeriAnes-thesia Nurses clinical guideline for the pre-vention of unplanned perioperativehypothermia. In: 2004 Standards of Peri-anesthesia Nursing. Cherry Hill, NJ: Ameri-can Society of PeriAnesthesia Nurses;2004:50-59.

3. Haas CE, LeBlanc JM. Acute postoperativehypertension: a review of therapeuticoptions. Am J Health System Pharm. 2004;61(16):1661-1673.

4. Malignant Hyperthermia Association of theUnited States. What is malignant hyperther-mia? 2009. http://www.mhaus.org/index.cfm/fuseaction/OnlineBrochures.Display/BrochurePK/8AABF3FB-13B0-430F-BE20FB32516B02D6.cfm. Accessed Novem-ber 12, 2009.

5. Litman RS, Rosenberg H. Malignant hyper-thermia. JAMA. 2005;293:2918-2924.

6. Rosenberg H, Davis M, James D, Pollock N,Stowell K. Malignant hyperthermia. OrphanetJ Rare Dis. 2007;2:21. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1867813.Accessed November 12, 2009.

7. Dell DD, Kehoe C. Plasma cholinesterasedeficiency. J Perianesth Nurs. 1996;11(5):304-308.

Hypertension is another com-mon postoperative complication. Itis thought to be related to sympa-thetic activation and can lead to car-diac, neurological, and surgical sitecomplications. Treatable causesinclude pain, anxiety, hypothermia,and hypoxia.3

Cardiac dysrhythmias maymanifest postoperatively; most com-monly, bradycardia, tachycardia,and premature ventricular contrac-tions occur. Ventricular tachycardiaor fibrillation may occur in patientswith electrolyte imbalances, hypox-emia, or hypothermia. Guidelinesof the American Heart Associationshould form the basis for treatmentof postoperative dysrhythmias.

Malignant hyperthermia is agenetic disorder and a hypermeta-bolic response to select inhalationagents and succinylcholine. Whenpatients are exposed to a triggeringagent, it causes release of calciuminside muscle cells, which causessustained muscle contraction, andincreased energy utilization. Whenmuscle cells run out of energy anddie, intracellular potassium spillsinto the bloodstream and myoglo-bin is released, which can lead tocardiac arrest, renal or liver failure,coagulopathies, or brain injury.4

Signs and symptoms associatedwith malignant hyperthermia includemuscle rigidity, tachycardia, tachyp-nea, elevated end-tidal carbon diox-ide, cyanosis, hyperkalemia, acidosis,and hyperthermia; the latter may bea late sign. Malignant hyperthermia

typically manifests in the operatingroom but may develop 24 hourspostoperatively.5

Malignant hyperthermia canbe treated with dantrolene sodium,which inhibits release of calcium,and hyperventilation with 100%oxygen to increase minute ventila-tion and lower carbon dioxide levels.Dantrolene dosing continues for atleast 48 hours. Other treatmentsinclude administration of sodiumbicarbonate, cooling measures, andtreatment of hypertension and dys-rhythmias.6

Pseudocholinesterase deficiencyis a rare genetic condition where thebody has a deficiency in that enzyme.7

Pseudocholinesterase is necessaryfor metabolism of succinylcholineand numerous anesthetic agents. Apatient with pseudocholinesterasedeficiency has prolonged paralysisand requires mechanical ventilationuntil the succinylcholine wears off.The patient should be reassured,and sedation and analgesics shouldbe provided as indicated.

Pain management should beginwhen the patient is admitted to theICU. Hypotension is a commonsequela of epidural anesthesia.Unless contraindicated, the head ofthe bed should be lowered and fluidreplacement should be started.

Patients in the immediate post-operative period have high levels ofvulnerability and complexity andhave uncertain levels of stability,resiliency, and predictability. ICUnurses caring for these patientsshould possess knowledge of anes-thetic agents and possible complica-tions and should be trained in thecare of these vulnerable patients. CCN

Financial DisclosuresNone reported.

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Roberta KaplowCare of Postanesthesia Patients

http://ccn.aacnjournals.org/Published online ©2010 American Association of Critical-Care Nurses

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