Perianesthesia Emergencies

Perianesthesia Emergencies

PeriAnesthesia Complications Lois Schick MN, MBA, RN, CPAN, CAPA, FASPAN Objectives Identify perianesthesia complications Identify pathophysiological changes of common postoperative problems State nursing interventions and treatment for each problem Respiratory Maintain pH of blood

Rids blood of CO2 Supplies Blood with Oxygen Airway Obstruction Loss of Pharyngeal muscle tone Soft tissue obstruction Tongue displacement Residual neuromuscular blockade Laryngospasm Airway edema Sleep Apnea AIRWAY OBSTRUCTION

Snoring - Flaring of nostrils - Retraction Asynchronous movement of chest and abdomen Increased accessory muscle usage Increased pulse Decreased Oxygen saturation Decreased Breath Sounds ASPIRATION Factors related to aspiration pneumonitis

Increased gastric residual volume Decreased gastric pH Presence of particulate matter in stomach Difficulty in protecting airway HIGHER RISK POPULATIONS Morbid obese Diabetics Surgical factors 1. Upper abdomen surgery 2. Straining on ETT

OB patients Emergency patients: MVA TYPES OF ASPIRATION Large particle- immediate intervention required Clear acidic fluid -pH of aspirated material determines extent of pulmonary injury Clear nonacidic fluid- depends on volume and composition Food stuff or small particle -within 6 hours may see severe hemorrhagic pneumonia Contaminated material -bowel, dental ASPIRATION

SIGNS & SYMPTOMS Tachypnea Tachycardia Hypoxia Chest infiltrate Wheezing Coughing - dyspnea Apnea Hypotension Bradycardia INTERVENTIONS Position on side with head turned

Bronch if large particles Oxygen Ventilate if needed Inotropic medications Antiemetics INTERVENTIONS for Airway Obstruction Chin support/Jaw thrust/head tilt Remove, reposition airways (oropharyngeal, nasal trumpets) Positive Pressure with mask/ambu Dentures

HOB Elevated unless contraindicated Cricothyrotomy LARYNGOSPASM Anesthetic agents Asthma history Irritable airway Smoking COPD Endotracheal tube usage- irritation Vocal cord irritation

Secretions Blood Vomitus SIGNS & SYMPTOMS Dyspnea, Decreased SpO2 Hypoxia Hypoventilation Crowing Sounds, inspiratory stridor, retractions Hypercarbia Agitation Paradoxical rocking motion Accessory muscle use

INTERVENTIONS for Laryngospasm Hyperextend head Medications Oxygen Elevate Head of Bed Racemic Epinepherine Intubation Dexamethasone Positive pressure Lidocaine ventilation (BVM) Atropine Sedation

Muscle Relaxants BRONCHOSPASM Associated with: Asthma COPD Smoking Light anesthesia Residual effect of muscle relaxants Irritable tracheobronchial tree Mechanical factors

Signs & Symptoms Wheezing Shallow noisy respiration Chest retractions Dyspnea Tachypnea Decreased P02 Use of accessory muscles Interventions for Bronchospasm Remove irritant Increase Oxygen Administer muscle relaxants Deepen anesthesia

Administer medications Nebulizer with Bronchodilators (Terbutaline or Albuterol) IV Theophylline Steroids (Solu-Medrol or Prednisone) Hypoxemia Atelectasis (Alveolar collapse) Reduced basal air entry Reduced lung volumes on chest x-ray May start immediately but becomes more severe during the 2nd postop day to 4-5th night Due to residual anesthetic effect, upper airway obstruction from airway tissue edema

Accumulation of pharyngeal secretions, prolapse of the tongue posteriorly, tongue edema or an allergic reaction Treatment: Pre and Postop physiotherapy Humidified oxygen Stir up regimen deep breathe, cough, early mobilization Analgesia to allod for deep respirations

Continuous positive airway pressure Hypoventilation Drug induced CNS depression Residual effects of NMB Suboptimal ventilatory muscle mechanics Increased production of Carbon dioxide Coexisting COPD Desaturation most frequent event Greater than 60 years of age Obese patients Longer operations High dose opioid use

Hoarseness and Sore Throat Usually does not cause airway problems unless patient was intubated Spontaneous resolution occurs within 2 weeks Prevention and Treatment: Aerolized beclomethasone prior to intubation Use of experienced intubator Use of bland lubricant Throat lozenge

Warm fluids Pulmonary Edema Cardiogenic Intravascular volume overload Cardiac dysfunction NonCardiogenic Pulmonary Aspiration Sepsis Airway obstruction Transfusion of blood

products (TRALI transfusion related acute lung injury) PULMONARY EDEMA SIGNS & SYMPTOMS Tachypnea with respiratory distress Shortness of Breath Adventious Breath Sounds Pink frothy sputum Pulmonary infiltrates

INTERVENTIONS Oxygen Pulmonary toilet Maintain unobstructed airway Diuretics Fluid restriction Morphine Sulfate Pneumothorax Types: Penetrating Tension Causes

External procedures Central line placement, biopsies Internal procedures tracheal/bronchial tree injury Fractured ribs,crush injury, CPR Blunt trauma deceleration injury Airway overpressure Pneumothorax Signs

Respiratory distress Difficulty ventilating Desaturation Hypotension

Heart rate changes Unilateral chest expansion Abdominal distention Distended neck veins - CVP Tracheal deviation in tension pneumo Pneumothorax Interventions: Chest x-ray

Smaller pneumothorax tincture of time Medium to large chest tube Emergent needle decompression into affected side Use 10-20 ml syringe with 23 g needle Allow 3 rib mid-clavicular line or above 4th mid-rib axillary line Allergic Reactions Signs & Symptoms Conjunctivitis Uriticaria Angioedema Gastrointestinal disturbances Laryngeal edema

Bronchospasm Hypotension Dysrhythmias Cardiac arrest Coma TREATMENT Adrenergic agonists ( Epinepherine) Methylxanthines (Aminophyllin) Anticholinergics (Atropine, Glycopyrollate, Scopolamine) Antihistamines ( Benadryl) Corticosteroids

Cardiovascular Transports nutrients to body cells Transports waste from cell Dysrhythmias Hypotension Hypertension Acute Myocardial Infarction DYSRHYTHMIA CAUSES Electrolyte Imbalance - Preop cardiac dysrhythmias Hypokalemia & Hypovolemia hypocalcemia

Myocardial ischemia Hypoventilation Anticholinesterase meds Pain Respiratory Acidosis Hypertension Hypoxemia Hypothermia Fluid overload DYSRHYTHMIAS REQUIRING TREATMENT Atrial Flutter Atrial Fibrillation

Paroxsymal Atrial Tachycardia Nodal Tachycardia Second & third degree heart blocks Premature Ventricular Contractions Bradycardia if symptomatic O Schick DYSRHYTHMIAS REQUIRING TREATMENT Ventricular Tachycardia Ventricular Fibrillation Asystole PEA (Pulseless Electrical Activity )

DYSRHYTHMIA TREATMENT Bradydysrhythmias Oxygen 1st line drug EKG Correct underlying cause Assure patency of airway Chest pain is always cardiac in origin until proven otherwise Conduction system Disruption

Heart surgery MI Treat with Dopamine, epi Tachydysrhythmias Pain Anxiety hypovolemia hyperthermia Treat with Beta blockers HYPOTENSION CAUSES Hypoxia Hypovolemia

Decreased Myocardial Contractility Sepsis Pulmonary embolus Pneumothorax VasoVagal Cardiac Tamponade Anesthetics Muscle Relaxants Narcotics Regional Anesthesia Artifact with equipment

Hypotension Signs BP, HR, Dysrhythmias HR may not decrease if cardioaccelerator fibers are blocked (epidural) Pallor, cool, moist skin, peripheral vasoconstriction Decreased mentation, nausea Decreased UO, concentrated urine Hypotension Characterized as Hypovolemic Decreased Preload

Decreased intravascular fluid volume/replacement Third Spacing Loss of sympathetic nervous system tone (Epi or spinal) Bleeding Cardiogenic Intrinsic Pump failure Myocardial Ischemia

Myocardial Infarction Cardiomyopathy Dysrhythmias Hypotension Distributive Decreased Afterload Iatrogenic sympathectomy from regional anesthesia Critically ill patients: Rely on exaggerated sympathetic nervous system tone. Minimal anesthetics can decrease sympathetic nervous tone Allergic Reactions Consider in all cases of sudden refractory extreme hypotension. Rx with Epi

Sepsis: (Fever and rigor) Blood cultures then antibiotics New Onset Hypotension in PACU Sign of: Drug overdose Drug interactions Hypovolemia HYPOTENSION TREATMENT Confirm accuracy of equipment Fluid Replacement Treat Dysrhythmias

Reverse anesthetics Afterload Reduction Elevate Legs Ephedrine Oxygen Inotropic Agents Calcium Dopamine Epi Dobutamine Cardioversion for tachdysrhythmias

HYPERTENSION Major Organs at Risk Heart - Myocardial Hypertrophy Kidney - Decreased perfusion, Renal Failure Brain - Loss of autoregulation HYPERTENSION CAUSES Full Bladder Emergence Stress Pre-Existing Drugs Pain

Urinary distention Hypervolemia Respiratory Insufficiency Abrupt Withdrawal of Clonidine Hypothermia Increased Intracranial Tricyclic Antidepressants Pressure TREATMENT for Hypertension Correct underlying etiology Diuretics

Vasodilators Hydralazine Nitroglycerin Nitroprusside Beta Blockers Propranolol Labetolol Esmolol Calcium Channel Blocker Nifedipine Environmental interventions

music, warmth ACUTE MYOCARDIAL INFARCTION Patients at risk Pre-existing coronary artery disease Diabetics Obesity Debilitated state Risk Factors for CAD Non Modifiable Sex Age

Ethnicity Genetics Modifiable Diabetic Hypertension Smoking Hyperlipidemia Obesity Sedentary Lifestyle Stress His n Hers Signs & Symptoms

Pain: heaviness, squeezing, pain in left chest, neck, Pain: Substernal abdomen, midback or shoulder characterized by or arm pain without pain in heavy, crushing or the mid chest squeezing commonly Pain is accompanied by N&V, occurring with indigestion, dyspnea, fatigue, exertion or emotion. diaphoresis, dizziness, fainting,

Rest or NTG may upper abdominal pain relieve pain May not respond to NTG or rest but Antacids may relieve pain His n Hers Signs & Symptoms EKG: Concurrent ST segment elevation is common Exercise Stress test is gold standard in detecting MI Stress echocardiogram useful

to text valves or ventricular function Cardiac Catheterization is a reliable diagnostic tool EKG: Concurrent ST elevation is less likely during MI Echocardiogram is more reliable than the exercise stress test Cardiac

catheterization is reliable but more risky in the woman. His n Hers Signs & Symptoms Mans larger vessels Bleeding at the allow better surgical site or visualization & fewer hemorrhagic stroke is complications during more likely with

percutaneous invasive procedures coronary intervention because of womans or CABG smaller vessels Deep Vein Thrombosis (DVT) CAUSES Vein wall injury OR straps, leg holders, knee rolls Hypercoagulation malignancy, pregnancy, dehydration, hypothermia Hemodynamic changes

stasis & turbulence from surgical positioning, immobilization, hypothermia, casts SIGNS Pain at or below level of clot Homans sign 50% reliable Swollen leg with pitting edema distal to clot Slight fever, chills, perspiration

CAN cause Pulmonary embolus and death DVT Prevention Sequential compression devices Hydration Avoid pressure on veins Anticoagulation Rx Low dose heparin Low molecular weight heparin

Warfarin (Coumadin Early ambulation/passive and active ROM Treatments Bedrest/leg elevation when swollen/painful Adequate hydration Clinical practice varies with MD Heparin/Coumadin (INR goal of 2.5) Fibrinolytics

Monitor labs: D-dimer, PT, PTT Vena cava filter TRALI (Transfusion Related Acute Lung Injury Patients received blood, coagulation factor or platelet intraoperatively Manifested within 1-2 hours after transfusion Can occur up to 6 hours after transfusion so may develop during PACU stay Noncardiogenic Pulmonary Edema associated with fever, systemic hypotension Underdiagnosed Elimination of female donors of FFP has decreased incidence.

Neurologic Regulatory control of all body systems, learning & Memory Delayed Awakening Emergence Excitement/delirium Delayed Arousal Should expect a response from patients within 60-90 minutes Etiology Prolonged action of anesthesia medications Metabolic causes Neurologic causes

Delayed Arousal ANESTHESIA CAUSES Residual anesthesia Hyperventilation due to high concentration of inhaled agents Narcotics may contribute to hypercarbia and sedation Hypothermia Delayed Arousal METABOLIC CAUSES Electrolyte imbalance Hepatic dysfunction

Hypocalcemia Renal disease Dilutional hyponatremia Diabetic ketoacidosis High magnesium levels Thyroid dysfunction especially eclamptic patients Malignant hyperthermia Delayed Arousal NEUROLOGIC CAUSES Ischemia Cardiovascular accident

Intracranial hemorrhage Air emboli Uncontrolled hypotension Embolism Mass lesions Seizure disorders Delayed Arousal INTERVENTIONS Assess oxygenation needs Ensure adequate oxygen exchange Reverse narcotics and benzodiazepines Warm patient if cold Treat electrolyte disturbance appropriately

Identify causes to treat specifically Emergence Delirium/Excitement 10% of adult patients >50 years of age Arterial hypoxemia Pre-existing cognitive disorder (Parkinson, dementia) Hypoventilation with hypercapnia Metabolic derangements renal, hepatic, edocrine Meds: Anticholinergics, Benzos, opioids, Beta Blockers Drug or ETOH withdrawal Electrolyte abnormalities Incomplete muscle relaxant reversal Acute CNS event hemorrage, ischemic stroke Seizures

Infection Urinary bladder distention EMERGENCE DELIRIUM CAUSES Anesthetic Agents Ketamine - Atropine Lidocaine - Droperidol Scopolamine Residual neuromuscular blockers Residual inhalation agents

SIGNS & SYMPTOMS Emergence Delirium Responsive or unresponsive agitation Unable to follow commands Irrational talking, screaming, shouting Low saturation levels Restlessness -Crying Disorientation -Tachycardia Confusion -Verbalizations INTERVENTIONS Emergence Delirium

Treat underlying cause Oxygen if indicated Opioids or sedation if needed Reverse narcotics or benzodiazepines Provide quiet environment Speak softly and directly to patient Maintain safety Anesthesia Related Complications Thermoregulation Malignant Hyperthermia (Emergency) Hypothermia Nausea and Vomiting

Anesthetic medications Patient positioning HYPOTHERMIA Causes Anesthesia Surgery Cold Operating Room HYPOTHERMIA Radiation - Heat transfer between two surfaces of different temperatures

Convection - Heat loss at a surface caused by fluid flowing across at a lower temperature Conduction - Heat transfer due to a temperature difference between two objects in contact Evaporation - Insensible water loss from skin, the respiratory tract, open incisions and wet drapes POTENTIAL COMPLICATIONS Wound infection Cardiac disturbances Altered medication effect Coagulopathy

Shivering Increased oxygen consumption Delayed emergency from anesthesia INTERVENTIONS Forced air warming devices Warmed cotton blankets Thermal drapes Fluid warmers Heat-moisture exchangers Heated humidifiers Warm operating rooms Infrared lights

Risk Factors for PONV Female patient Nonsmoker Long Surgery (>60 minutes) History of PONV History of Motion Sickness Use of Opioids Use of volatile anesthetics Use of Nitrous Oxide If 0 factors -20% risk If 1 factor 40% risk If 2 factors- 60% risk If 3 + factors 80% risk

NAUSEA & VOMITING PHYSIOLOGY Neuromuscular interaction Emetic Center Vagal viscera Sympathetic viscera Vestibular Cerebral Cortex/Limbic Chemoreceptor Trigger Zone (CTZ) PONV-PDNV CAUSES Blood sugar prolonged NPO; LR in OR

Na Fluid overload Hypotension/tachycardia/dysrhythmias Hypovolemia vasodilation, IV fluids, NPO, drains, insensible surgical loss, diarrhea, N/V preoperatively Hypoxemia - O2 & CO2 ICP, eye pressure, trauma Motion sickness whipping through the halls Physiology of Vomiting: Neurotransmitters Sensory input Higher

centers Cerebellum HM Vomiting center Solitary tract nucleus SDMH Brainstem Neurotransmitters M=Muscarinic cholinergic receptors

H = Histaminergic receptors D = Dopaminergic receptors S = Serotonergic receptors Chemoreceptor trigger zone SDM DS Upper gastrointestinal tract Brunton LL. In: Goodman and Gilmans The Pharmacological Basis of Therapeutics. 1996;917-936.

Inner ear vestibular apparatus M Toxins in blood and CSF ANTIEMETICS Serotonin (5HT3) Ondansetron (Zofram) Dolasetron mesylate

(Anzemet) Graniestron (Kytril) Palonosetron (Aloxi) Histamine (H1) Dopamine Receptors Butyrophenome Droperidol (Inapsine) Haloperidol Benzamides Metoclopramide (Reglan) Phenothiazines Prochlorperazine (Compazine)

Chlorpromazine (Thorazine) Hydroxyzine (Vistaril) Promethazine (Phenergan) Muscarinic (anticholinergics) Dimenhydrinate Transdermal Scope (Dramamine) Diphenhydramine NK-1 (Benadryl) Apprepitant - Emend OTHER: Ephedrine, Alcohol, Quease Ease

Comparative Receptor Affinities of Antiemetic Drug Classes Receptor Affinity Antiemetic Drug Class Dopamine Muscarinic Histamine Seroton Anticholinergic agent + ++++ + Antihistamines + ++ ++++ Phenothiazines ++++ ++ ++++

Butyrophenones Benzamides ++++ +++ Selective Serotonin Antagonists + + ++++ Ouellette SM. CRNA. 1999;10:24-33.

Adverse Effects Sedation: Anticholinergics, Phenothiazines, Antihistamines, Droperidol Hypotension: Promethazine, Prochlorperazine, Droperidol Extrapyramidal Symptoms: Phenothiazines, Metoclopramide, Droperidol Dry Mouth: Atropine, Scopolamine, Hydroxyzine, Antihistamines

Blurred Vision: Anticholinergics, Antihistamines Urinary Retention: Anticholinergics POSITIONING SUPINE Pressure points Nerve Injuries SITTING Postural Hypotension Airway embolism PRONE Eye abrasion

Ear compression Neck pain Nerve injury Joint damage LATERAL LITHOTOMY Orthopedic Complications Compartment Syndrome Nerve damage Compartment Syndrome Increased pressure within muscle compartment causes circulatory compromise

2 Main causes: Constriction from outside Increased pressure within compartment Compartment Syndrome When edema or bleeding increases pressure within a compartment impending circulation Signs & Symptoms Intense deep throbbing pain out of proportion to the injury without improving with analgesia Numbness & tingling distal to affected muscle Absent peripheral pulses Pallor or mottling of affected area

Decreased movement, muscle strength & sensation in affected extremity Sharp pain on passive stretching of middle finger or large toe of affected extremity Compartment Pain measurement 5 Ps P Pain P Paresthesia P Pallor P Paralysis P Pulselessness - poor prognostic sign

RISKS Constrictive casts & dressings Long bone fractures Orthopedic Surgery Crush injuries Thermal injuries Orthopedics Nerve Function Tests Radial: Sensory - pinch web site Motor - hyperextend thumb Median: Sensory - Pinch distal surface of

index finger Motor - Oppose thumb with little finger & flex wrist Ulnar: Sensory - Pinch distal end of little finger Motor - Abduct all fingers Orthopedics Peroneal: Sensory - Pinch lateral surface of great toe and medial surface of second toe Motor - Dorsiflex ankle & extend

toes Tibial: Sensory - Pinch medial and lateral surface of sole of foot Motor - plantar flex ankle, flex toes FAT EMBOLISM Seen with fractures of long bones Release of fat droplets into circulation Migrate to lungs Break down into acids irritates vascular walls causes extrusion of fluids into alveoli

alters ventilation leading to hypoxemia FAT EMBOLISM Tachypnea Tachycardia Anxiety Petechiae over chest Mechanical ventilation PO2 < 60 mm Hg Fever Confusion

Pallor FAT EMBOLISM Interventions Oxygen Keep patient quiet Prevent motion of fractured site Nerve Damage Nerve damage can be caused by diabetes, alcoholism, B-vitamin deficiencies and trauma such as car accident or sport injury. The main symptoms of nerve damage are: Numbness in hands, feet or other parts of the body. Numbness may develop gradually

Burning or stabbing pain. Pain may be intermittent Extreme sensitivity to touch. Even a light touch may cause pain Muscle weakness. The injured arm or leg fails to regain its previous strength Symptoms of nerve damage are frequently caused by injury or surgeryinduced inflammation and not by manipulation or cutting of nerves Renal Dysfunction Renal insufficiency leading to Acute Renal Failure Dehydration Hypovolemia Use of IV dyes Use of meds cleared via renal system Oliguria Low urine output (0.5 ml/kg/hour)

Pre-renal Hypoperfusion Hypotension Hypovolemia Reduced cardiac output Drugs that influence renal perfusion ( NSAIDS, ACE inhibitors, Angiotensin II receptor antagonists Renal intrinsic renal disease Ischemia from hypoperfusion

Nephrotoxins (aminoglycosides) Glomerula disease Post-renal Outflow obstruction Benign prostatic hypertrophy Blocked urinary catheter Inadequate urge to void ( post spinal) Renal calculi

Postoperative Urinary Retention Predictive event with: Anorectal surgery Joint replacement Periop meds used Anticholinergics B-Blockers Narcotics Risk Factors Age > 50 years Male gender Intraop fluid volume Duration of surgery

Bladder volume on admission Urine Retention Absence of voiding for 1st 12 hours post op Bladder distention above symphysis pubis Complaints of discomfort & pain in bladder area Anxiety & restlessness Hypertension Help pt. ambulate ASAP

Help into normal voiding position Prepare for catheterization Adult capacity: 350 to 700 ml urge to void with 150 ml bladder fullness 400-450 ml Endocrine System Regulates secretion of hormones that alter metabolic body functions:

Chemical reactions & transport of chemicals Growth & development Metabolism Fluid & Electrolyte balance Acid Base balance Adaptation Reproduction

Endocrine System Regulates & integrates bodys metabolic activities Maintains internal homeostasis Consists of Glands- Secrete hormones and chemical transmitters Hormones- chemical substances secreted by glands Receptors Protein molecules that trigger physiologic changes to hormone stimulation Endocrine System Major glands include Pituitary gland Thyroid gland

Parathyroid glands Adrenal glands Pancreas Thymus Pineal gland Gonads Potential Endocrine Disorders Addisons disease Adrenal hypofunction (insufficiency) Progress to Addisonian Crisis deficiency of mineralcorticoids and glucocorticoids Acute Addisonian crisis both hormones suddenly depleted BP drops due to vascular collapse Pressor therapy is difficult to regulate

Blood glucose plummets and coma & death ensue Treatment with Hydrocortisone, aggressive fluids vasopressors, blood glucose management Potential Endocrine Disorders Diabetes Insipidus: Water metabolism disorder caused by deficiency of ADH (Vasopressin). Filtered water is excreted rather than be absorbed Causes: Pituitary tumor, Hypothalmic tumor, cranial trauma, stroke Medications including Lithium, Phenytoin, Alcohol Potential Endocrine Disorders

Diabetes Mellitus: Chronic disease of insulin deficiency or resistance Disturbances in carbohydrate, protein or fat metabolism Type I: Autoimmune process Type II: Beta cell exhaustion due to lifestyle habits & hereditary factors Potential Endocrine Disorders Diabetic Ketoacidosis: Acute complication of hyperglycemic crisis in patients with diabetes. May result from:

Infection Illness Surgery Stress Insufficient or absent insulin Potential Endocrine Disorders Hyperosmolar Hyperglycemic Nonketotic Sydrome: Acute hyperglycemic crisis accompanied by hyperosmolality and severe dehydration without ketoacidosis Most common in type II diabetics but can occur in pts having peritoneal dialysis, hemodialysis or total parenteral nutrition

Ketones are absent so no acidosis Potential Endocrine Disorders Myxedema Coma progresses from hypothyroidism Primary hypothyroidism is disorder of thyroid gland Secondary hypothyroidism is caused by failure to stimulate normal thyroid function or inablility to synthesize thyroid hormone due to iodine deficiency or use of antithyroid meds Treat with Hydrocortisone and Levothyroxine, fluids, ventilation warming devices Potential Endocrine Disorders Syndrome of Inappropriate antidiuretic hormone (SIADH) Common complication after surgery. ADH is secreted & body retains

water Causes: Oat-cell lung cancer, Neoplastic disease, Brain abscess, Stroke, Guillain-Barre syndrome, pulmonary disorders, adrenal insufficiency, anterior pituitary insufficiency Potential Endocrine Disorders Thyroid Storm(thyrotoxic crisis) Have a surge of thyroid hormones Signs & Symptoms

Tachycardia Irritability and restlessness Tremor Weakness Heat intolerance Angina Shortness of breath Exophthalmos QUESTIONS?

References Drain, Cecil & Jan Odom-Forren. Perianesthesia Nursing: A Critical Care Approach. 5th edition St. Louis: Saunders Elsevier. 2009. Litwack, Kim. Clinical Coach for Effective Perioperative Nursing Care. 2009. Philadelphia: F.A. Davis Company. Nagelhout, John & Karen Plaus. Handbook of Nurse Anesthesia. 4th Edition. St. Louis: Saunders Elsevier. 2010 Schick, Lois & Pam Windle (Editors) Perianesthesia Nursing Core Curriculum: Preprocedure, Phase I and Phase II PACU nursing. 2nd Edition . St. Louis: Mosby Elsevier. 2010. Skidmore-Roth, Linda. Herbs & Natural supplements. 4th edition. St. Louis: Mosby Elsevier. 2010. Ziolkowski, Linda. Herbal Agens and the Perianesthesia Patient Presentation April 21, 2009 at 28th ASPAN National Conference in Washington, D.C.

References ASPAN Perianesthesia Nursing Standards and Practice Recommendations 2010-2012. Cherry Hill, NJ: American Society of PeriAnesthesia Nurses, 2010 Atlee, John. Complications in Anesthesia. 2nd Edition. Philadelphia: Elsevier. 2007 Chung, F: Discharge criteria- a new trend. Can J. Anaesth 42(11): 1056 Saunders Cole, Daniel and Michelle Schlunt. Adult Perioperative Anesthesia: The in Anesthesiology. Philadelphia: Mosby Elsevier. 2004

Requisites Odom-Forren, Jan. Drains Perianesthesia Nursing: A Critical Care edition. St. Louis, MO: Saunders Elsevier. 2013 Litwack, Kim. Clinical Coach for Effective Perioperative Nursing Care. Philadelphia: F.A. Davis Company. 2009 Approach. 6th References Pasero, Chris & Margo McCaffery. Pain Assessment and Pharmacologic Management. St. Louis: Elsevier Mosby. 2012 Putrycus, Barbara & Jacqueline Ross. ASPANs Certification Review

for Perianesthesia Nursing. St. Louis: Elsevier Saunders 2013 Reed, Alan. Clinical Cases in Anesthesia. 2nd Edition. New York: Churchill Livingstone.1995 Schick, Lois and Pamela Windle (Editors) PeriAnesthesia Nursing Core Curriculum: Preprocedure, Phase I and Phase II PACU Nursing. 2nd Edition. St. Louis, MO: Saunders Elsevier, 2010. Stannard, Daphne and Dina Krenzischek. PeriAnesthesia Nursing Care: A Bedside guide for safe recovery. Sulbery MA: Jones & Bartlett Learning. 2012

ON Line References His and hers heart disease accessed at Obstructive Sleep Apnea. Accessed at Pulmonary Disorders accessed at Sutherland, Sara. Pulmonary Embolism: Treatment and Medication at What is Obstructive Sleep Apnea (OSA)? Accessed at

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