Edward Fohrman shares some valuable insight into the postanesthesia recovery process. For information about Edward and his work, visit EdwardFohrman.com

1. Edward B. Fohrman M.D
Assistant Professor, Department of Anesthesiology
Northwestern University, Feinberg School of Medicine
POSTANESTHESIA RECOVERY

2. CASE
▪ 55 y.o. male s/p robotic prostatectomy
otherwise uneventful…
▪ Surgery is over
▪ Volatile agent is off
▪ Reversal given
▪ HOW DO U KNOW WHEN PT. IS READY FOR
EXTUBATION???

3. EXTUBATION CRITERIA?
▪ PaO2/FiO2 > 300
▪ PaCO2 < 50 mmHg
▪ Vd/Vt < 0.6
▪ RR < 35
▪ Vt > 5 ml/kg
▪ NIF > (-20 mm H20)
▪ TOF ratio > 0.9
▪ Clinical Strength (5 sec head lift)
▪ Mental Status c/w ability to maintain airway
▪ No Airway Edema/Vocal cord paralysis or other cause of airway
obstruction
▪ Hemodynamic Stability

4. When to transfer to PACU?
▪ ABC’s
▪ Patent or secure airway
▪ Adequate Oxygenation & Ventilation
▪ Hemodynamically stable

5. O2 During Transport?
1) <93% after extubated in OR
2) Unconscious
3) Age > 60
4) Wgt > 100 kg
5) Pulmonary disease
6) Difficult airway
7) OSA
8) Surgery: Abd., Thoracic, Neuro, Cardiac, ENT
9) N2O (avoid diffusion hypoxia)
10) SpO2 < 93% upon arrival to PACU
Probably NOT necessary in LOW RISK patient
population…
“Favor using O2 in anyone who’s physiology would
be negatively affected by even a brief hypoxemic
episode”

6. How much O2 R U giving?
Each liter of Nasal Cannula O2 increases
FiO2 by 3 - 4%
(Starting from room air 21%)
Nasal cannula does not suppress
respiratory drive even in COPD
It is impossible to deliver more than 40%
FiO2 with N.C. due to limitations in flow
dynamics
*DELIVERY OF 100% O2 can only be
achieved with INTUBATION!!!
Short of this, the highest O2 delivery can
be achieved with a high flow, 10L
“Nonrebreather” Face mask ≈ 90% FiO2
Miller’s Anesthesia 6th Ed. 2005

7. Admission to the PACU
▪ Patient’s name & age
▪ Surgical procedure/Anes type
▪ Coexisting medical probs
▪ Allergies
▪ Fluids: EBL, IVF, UOP
▪ Anes/Surgical complications
▪ (difficult airway?)
▪ Special requests: meds, labs, x-rays
▪ Lines/Location (a-line, iv’s, epidural)

8. Early Post-Op Physiologic Disorders
▪ Upper Airway
Obstruction
▪ Arterial Hypoxemia
▪ Hypoventilation
▪ Hypotension
▪ Hypertension
▪ Cardiac Dysrhythmias
▪ Oliguria
▪ Bleeding
▪ Hypothermia
▪ Agitation/ Emergence
Delirium
▪ Delayed Awakening
▪ Nausea & Vomiting

9. Case
▪ 52 y.o. male s/p C4-6 ACDF brought to
PACU after extubation
▪ 20 min later to inform u patient is
tachypneic with SpO2 91
▪ DDX?
▪ What else do you want to know?
▪ What’s your next move???

10. Case
▪ 8 y.o. male s/p inguinal hernia repair brought to PACU
after deep extubation
▪ The patient suddenly bucks and begins to desaturate
rapidly…DDX? Treatment?
▪ What is Stage 2 anesthesia and why is it significant?
▪ How do you know when a patient is in stage 2
anesthesia?

11. Upper Airway Obstruction
▪ Loss of pharyngeal muscle tone
▪ Obstructive Sleep Apnea (OSA)
▪ Laryngospasm
▪ Deep extubation? / Tx?
▪ Airway edema
▪ ↑IVF, ↑EBL, ↑Duration, Prone position
▪ Surgery of tongue, pharynx, neck, thyroid, CEA
▪ CUFF TEST
▪ Neck hematoma
▪ Monitor airway patency during transport –
(Look, Listen, Feel)

12. Residual Neuromuscular Blockade
▪ Assessment of adequate reversal?
▪ TOF, DBS, Clinical sx
▪ What factors increase risk of residual block?
▪ Drugs – Volatiles, local, Antiarrhythmics, Antibiotics, Corticosteroids,
CCB’s, Dantrolene, Lasix, BCP’s
▪ Metabolic Physiologic states - ↑Mg, ↓Ca, Hypothermia, acidosis, liver/
renal failure, Myasthenia Gravis, Extremes of age
▪ Prolonged Depolarizing block
▪ Atypical pseudocholinesterase, Phase II block, Pregnancy, Echothiophate
(irreversible), Edro, Neo, Pyrido (reversible)

13. Classification of NMB’s
Depolarizing
▪ Succinylcholine
Nondepolarizing
➢ Short Acting
➢Mivacurium
➢Rapacuronium
➢ Intermediate Acting
➢Rocuronium
➢Vecuronium
➢Cisatracurium
➢Atracurium
➢ Long Acting
➢Pancuronium

14. Case
▪ You just “deep” extubated your patient to avoid
bucking on the tube after an otoplasty. As you are
moving the patient to the gurney, the patient
bucks and coughs and begins to turn blue.
▪ More good news…your IV was inadvertantly pulled
out during the move and is now dripping on the O.R.
floor…
▪ What’s the problem and how are you going to save
the day?

15. Succinylcholine
• 2 Ach molecules linked by methyl groups
• Agonist action binds the alpha subunit and leads to muscle contraction and
refractory period
• Depolarizing block also called Phase I block
• Intubating dose: 1-1.5mg/kg (ED95 = 0.3mg/kg)
• Onset 30-60 secs and duration 5-10 minutes
• Defasciculating dose of nondepolarizer
• (5-10% of ED95 2-4 min prior) must increase sux dose by 70%
•Repeated doses > 3-5mg/kg >>> Phase II block
•Serum potassium (K+) by 0.5 to 1 mEq/L
• EJnAchR’s increase K+ ???

16. Why Sux is unique?
▪ The only Depolarizing blocker used
clinically today
▪ Most rapid onset of any other NMB
▪ Most rapid recovery/offset of any NMB
▪ Most significant degree of vocal cord
paralysis/BEST intubating conditions
▪ Only NMB with rapid effects when given
I.M. in cases of no IV access…IM dose?

17. Each of the following patients requires
urgent intubation…what do they all
have in common???
75 y.o. male s/p ischemic CVA 3 weeks ago with
residual left hemiparesis
21 y.o. female PMH - MVA 4 years ago with
incomplete T4 level – urosepsis/pneumonia and
SpO2 89%
18 y.o. male s/p GSW to head, in barb coma w/
vecuronium gtt x 7 days who was inadvertantly
extubated by the RN…

18. Sux: Adverse side effects
▪ Hyperkalemia!!!
▪ Note: 1mg/kg Sux does NOT increase ICP (Kovarik et al.
Anesthesia&Analgesia, 1994;78:469-73
▪ Myoglobuinuria – Malignant Hyperthermia (MH)
▪ Cardiac dysrhythmias (esp. 2nd dose!)
▪ Sinus brady, Jct brady, Sinus arrest
▪ Fasciculations
▪ Myalgia (especially in outpatients)
▪ Increased intraocular pressure (not more than bucking)
▪ Increased intragastric pressure
▪ Trismus - Masseter muscle rigidity common in peds (4%)
▪ Associated with subsequent development of MH

19. “Extrajunctional Receptors”
Normal
Denervation

20. Effect of Sux on denervated muscle
Martin and Richtsfeld, Anesthesiology, 2006;104:158-69

21. Up/Down Regulation of nAChR
Martin and Richtsfeld, Anesthesiiology, 2006;104:158-69

22. ▪ 22 y.o. 70 kg. male without significant
PMH/PSH undergoes a RSI for acute
appendicitis. 10 min after 1mg/kg of sux,
the patient receives a 30mg dose of ROC.
▪ The case goes well and the surgeon begins
skin closure.
▪ TOF reveals that the patient still has no
twitches 1 hour after the last dose of
ROC….WHY?
CASE

23. Atypical Cholinesterase
▪ Check TOF after sux, (before NDNMB)
▪ Dx after a patient has a prolonged response to
sux or mivacurium (>1hour)
▪ Dibucaine Number
▪ Dibucaine – amide local anesthetic
▪ Inhibits normal enzyme by 80%
▪ Inhibits abnormal enzyme by only 20%

24. Variants of Plasma Cholinesterase and Duration of action of
Succinylcholine
Variants of Plasma
Cholinesterase Incidence
Dibucaine Number
(% Inhibition of
enzyme activity)
Duration of
succinylcholine
induced
neuromuscular
blockade (min)
Homozygous
Typical
Normal 70-80 5-10
Heterozygous 1 in 480 50-60 20
Homozygous
Atypical
1 in 3200 20-30 60-180
Stoelting & Miller, Basics of Anesthesia. 2007

25. Martin and Richtsfeld, Anesthesiology, 2006;104:158-69

26. Arterial Hypoxemia
▪ R > L Shunt
▪ Atelectasis
▪ V/Q Mismatch
▪ ↓FRC
▪ CHF
▪ Pulmonary Edema
▪ Alveolar Hypoventilation
▪ Drugs: (NMBs, Narcotics,Volatiles)
▪ Increased CO2 production/
COPD
▪ Suboptimal ventilatory
mechanics
▪ Aspiration
▪ PE
▪ PTX
▪ ↑O2 Consumption
▪ Shivering
▪ Sepsis
▪ TRALI
▪ ARDS
▪ Advanced age
▪ Obesity
▪ Diffusion Hypoxia

27. 6 Causes of Arterial Hypoxemia
1. Low FiO2
2. Hypoventilation
▪ Muscle relaxants, narcotics, pain/splinting
▪ PAO2 = FiO2(PB760-PH2047) – (PCO2/RQ)

28. Arterial Hypoxemia
3. Shunt V/Q = 0 (Absolute shunt)
▪ perfusion without ventilation
▪ PTX, bronchial intubation/single lung ventilation, R>L
cardiac shunt, ARDS/sepsis, liver failure, AVM, atelectasis,
pneumonia/mucous plugging, pulmonary contusion,
bronchospasm, CHF
▪ Shunted blood is NOT exposed to alveoli, thus O2
unresponsive for shunt > 30%
▪ Shunt fraction = Qs/Qt = CcO2-CaO2/CcO2-CvO2
▪ 2 sources of normal shunt: Bronchial arteries and
thebesian veins. (Normally 2-5%)

29. Arterial Hypoxemia
4. V/Q Mismatch V/Q = ∞
Dead space: ventilation without perfusion V/Q>1
i.e. Pulmonary Embolus
V/Q matching optimally should be 1:1
Hypoxic Pulmonary Vasoconstriction (HPV)
5. Diffusion defects
Advanced pulmonary disease, pulmonary edema, ARDS
6. ↑Venous Admixture
(Low cardiac output states)
O2 Delivery = O2 content x Cardiac Output
O2 Content = 1.34 x Hgb x SaO2 + (PaO2 x 0.003)
Decreased CO, ↑ O2 consumption, Anemia,
Hgb dysfct.

30. Shunt – Response to O2
▪ Increasing FiO2 from room
air to 100% results in a
large increase in PaO2
when the shunt fraction is
small; however,
oxygen will have
little effect on PaO2
in patients with a
large shunt fraction
Miller’s Anesthesia 6th Edition, 2005

31. Case
▪ 38 y.o. female s/p scoliosis repair is
brought to the ICU intubated.
▪ You note SpO2 of 89% and absent BS on
the Left chest
▪ You ask for a stat CXR for line placement
(left SCV cordis)
▪ What’s your next move???

32. Pulmonary Edema
▪ Fluid Overload
▪ Iatrogenic: Large IVF, Blood transfusions (TACO)
▪ ESRD/CRF
▪ Cardiogenic/CHF
▪ MI, Arrhythmia, Valvular lesion
▪ Euvolemic
▪ ARDS
▪ Catecholamine surge
▪ Neurogenic/SAH
▪ TRALI (up to 6hr post tx delay, leukopenia)
▪ Negative Pressure Pulmonary Edema

33. Reintubation in PACU?
▪ PaO2/FiO2 ratio < 300
▪ Respiratory rate > 35 breaths/minute
▪ Tidal Volume Vt < 5 cc/kg
▪ Vital capacity <15ml/kg (adults) <10ml/kg (peds)
▪ Negative inspiratory force of < -20 mmHg
▪ PaO2 < 70 mmHg on 40% FiO2
▪ PaCO2 > 55-60 mmHg (except chronic CO2 retainers i.e.COPD)
▪ Alveolar-arterial (A-a) gradient > 350 mmHg on 100% FiO2
▪ Dead Space (VD/VT) > 0.6
▪ Hemodynamic instability?
▪ WHAT DOES THE PATIENT LOOK LIKE???

34. Case
▪ 68 y.o. male s/p RLL Lobectomy under GA,
Thoracic epidural, Dbl lumen ETT, now
extubated to PACU
▪ BP 70/40, HR 120, SpO2 93%
▪ DDX?
▪ What’s your next move???

35. HYPOTENSION
BP = CO x SVR
CO = SV x HR SVR = MAP- CVP
CO
Preload
Afterload
Cardiac Contractility

36. Hypotension
▪ ↓Intravascular Volume (Preload)
▪ (PCWP<5-10mmHg) with normal CI (2.5-4.0)
▪Bleeding!
▪Bleeding!!
▪Bleeding!!!
▪3rd Spacing
▪Insensible losses

37. Hypotension
▪ ↓Cardiac Output (Intrinsic pump failure)
▪CO = HR x SV (CI < 2.5)
▪ MI
▪ Cardiomyopathy
▪ Valvular Dz
▪ Pericardial Dz
▪ Tamponade
▪ Dysrhythmias
▪ PE
▪ Tension PTX
▪ Drugs (Beta Blockers, CCBs)

38. Hypotension
▪ ↓Systemic Vascular Resistance (Afterload)
▪ SVR = (MAP-CVP/CO) x 80 (900 to 1400 dynes/
sec/cm-5)
▪ Sepsis / SIRS
▪ Anaphylaxis
▪ Spinal Shock (SCI, Epidural/High Spinal)
▪ Adrenal Insufficiency

39. Case
▪ 68 y.o. male s/p Left CEA under GA now
extubated to PACU
▪ BP 198/100, HR 61, SpO2 97%
▪ DDX?
▪ What’s your next move???

40. Hypertension
▪ A-line transducer level?
▪ Emergence Excitement?
▪ Arterial Hypoxemia
▪ Enhanced Sympathetic Tone
▪ PAIN, PAIN, PAIN
▪ Hypoventilation/Hypercapnia
▪ Autonomic Hyperreflexia, Carotid surgery
▪ Bladder distention/ Gastric distention
▪ Essential HTN – Preop
▪ Hypervolemia/Fluid Overload
▪ Shivering
▪ Drugs/ Drug Rebound
▪ ↑ ICP
▪ Thyrotoxicosis, Pheochromocytoma

41. Cardiac issues in PACU
▪ Risk factors for CAD
▪ Smoking
▪ HTN
▪ Hypercholesterolemia
▪ Diabetes Mellitus
▪ Obesity
▪ Physical Inactivity
▪ Family History
▪ (1st order relative prior to age 55)
Identify patients at risk!

42. ECG ∆’s in PACU
▪ Low Risk Patient ?
▪ Age < 45
▪ No known Cardiac History
▪ Only 1 Cardiac Risk Factor
▪ Post op ST ∆’s = MI? Usually NOT
▪ Usually benign and do not require more than routine PACU observation
unless associated dysrhythmia and/or hemodynamic instability
DON’T DO A MILLION $ Work UP!!!

43. ECG ∆’s (High Risk)
▪ Who is High Risk?
▪ Post op ST and T ∆’s may be significant even in the absence
of typical sx
▪ 12 lead ECG (vs. preop ECG)
▪ Serial Troponin-I (cTni), CBC, Chem, ABG
▪ O2, NTP/NTG, Beta Blockade
▪ If BP unstable
▪ consider re-intubation/echo/PA catheter/Inotropes
▪ Notify primary service/ discuss your concerns
▪ Cardiology consult/ follow-up
▪ Disposition – Tele, ICU, floor?

44. Cardiac Dysrhythmias
▪ Hypoxemia
▪ Hypercarbia
▪ Volume Shifts/Fluid Overload
▪ Myocardial Ischemia
▪ Electrolyte Abnormalities
▪ Acidosis
▪ Anemia
▪ Pain, Agitation,
Hypothermia
▪ HTN
▪ Preoperative Cardiac
Dysrhythmia
▪ Drugs/ Withdrawal
▪ Digoxin Toxicity
▪ Anticholinesterases
▪ Anticholinergics
▪ PE
▪ PTX/Line placement
▪ SIRS
▪ MH
▪ Thyroid storm/Pheo

45. Case
▪ 44 y.o. male patient s/p appy
▪ 5 minutes after giving report, the patient’s HR
is 40…
▪ What else do you want to know?
▪ What are you going to do?

46. Atrial Dysrhythmias
▪ Noncardiac Surgery (10%)
▪ Cardiothoracic Surgery (25-30%)
▪ Associated with longer hospital stay and higher
mortality
▪ Electrical Cardioversion vs. ctrl Ventricular response
– CCB, β-Blockade, Amiodarone
▪ Vagal maneuvers, adenosine to distinguish between
SVT and A-fib/flutter

47. Ventricular Dysrhythmias
▪ PVC’s, Ventricular Bigeminy are common, but
rarely degenerate into V-tach
▪ PVC’s may just reflect ↑ sympathetic stim.
(hypercapnia, intubation)
▪ Multifocal PVC’s vs. Unifocal PVC’s?
▪ Consider ABG, CBC, Chem, cTni if suspect
myocardial ischemia – Torsades, QT
prolongation?
▪ Electrical Cardioversion vs. Amiodarone

48. Case
▪ 81 y.o. male s/p Right Hip Pinning under
GA, now extubated to PACU
▪ Mr. Cartman is confused…
▪ DDX?
▪ What’s your next move?

49. Delirium
▪ An acute change in cognition or
disturbance of consciousness that
cannot be attributed to a
preexisting medical condition ,
substance intoxication, or
medication.
▪ 10% Incidence: > 50 y.o.
undergoing elective surgery up to
POD #5
▪ Higher incidence (30%) after Hip
ORIF and Bilateral TKR

50. Risk Factors: Post-Op Delirium
▪ Advanced age
▪ Preoperative cognitive impairment
▪ Decreased functional status
▪ ETOH abuse
▪ History of delirium

51. Management of Post-Op Delirium
▪ Vitals!
▪ Patient Safety
▪ Restraints
▪ Physical ( soft restraint/full restraint)
▪ Chemical (Versed, Physostigmine, Antipsychotics
(Haldol)
▪ Even if it means Reintubation!
▪ Work-UP Etiology…

52. DDX Delirium
▪ Arterial Hypoxemia
▪ Preexisting Cognitive Disorder
▪ Dementia, Parkinson’s vs. conversion rxn
▪ Hypoventilation/Hypercapnia
▪ Metabolic Derangements
▪ Renal/Hepatic insufficiency, Acidosis, Electrolyte abnormalities
▪ Drugs
▪ Anticholinergics, BDZ’s, Opioids, β-Blockers, Reglan
▪ CNS
▪ Ischemic/Hemorrhagic CVA, Seizures
▪ Infection/SIRS
▪ Emergence Excitement:
▪ 30% of peds, peak age 2-4 y.o.

53. Case
▪ 49 y.o. male s/p ex-lap for perforated
diverticulitis under GA, now extubated to
PACU
▪ Patient has no urine output from the
foley
▪ DDX?
▪ What’s your next move?

54. Oliguria
▪ Most commonly “pre-renal” from depletion of intravascular
volume
▪ Usually responds to a 500-1000ml bolus
▪ Check Hct to rule out surgical bleeding
▪ d/w surgeon/?check bladder pressure to rule out intra-
abdominal htn
▪ Intra-abdominal Pressure > 30cm H2O can impair renal
perfusion
▪ Value of fractional excretion of sodium (FeNa) is limited in the
PACU and confounded by diuretics
▪ In cases where the patient’s volume status and/or cardiac
function is in question (MI, CHF, SIRS), consider placing a PA
Catheter/or obtaining an echocardiogram

55. Renal Dysfunction
▪ Oliguria (<0.5 ml/kg/hr)
▪ Preop vs. Intraop vs. Postop
▪ Usually multifactorial (i.e. Preexisting
CRI confounded by an intraoperative
insult)
▪ Focus on “treatable causes” in PACU
Classification
• Prerenal
• Renal
• Postrenal

56. Postoperative Oliguria
▪ Prerenal
▪ Hypovolemia
▪Bleeding, Bleeding, Bleeding
▪3rd Spacing, Insensible losses
▪Inadequate volume resuscitation
▪ Hepatorenal syndrome
▪ Low Cardiac Index (MI, CHF,)
▪ SIRS
▪ Renal Vascular Obstruction/
Disruption
▪ Abdominal Compartment Syndrome

57. Postoperative Oliguria
▪ Renal
▪ Ischemia (ATN)
▪ Contrast/IVP Dyes
▪ Rhabdomyolysis (Alkalinize
urine/mannitol)
▪ Tumor lysis
▪ Hemolysis

58. Postoperative Oliguria
▪ Postrenal
▪ Surgical injury to Ureter(s)
▪ Ureteral obstruction (Stone,
Clots)
▪ Mechanical (Foley Catheter
obstruction/Malposition

59. Body Temperature & Shivering
▪ Postoperative shivering
▪ Incidence: 5%→65%
▪ Mechanism
▪ Hypothermia- thermoregulatory center
▪ Normothermia- more rapid recovery of spinal cord function,
uninhibited spinal reflexes→ clonic activity
▪ Treatment
▪ Identification of hypothermia by core body temp
▪ Forced air warmers
▪ Opioids, Clonidine, Meperidine (most effective)

60. Body Temperature & Shivering
▪ Clinical Effects
▪ Increases O2 consumption and CO2 production
▪ Increased CO, HR and BP
▪ Inhibition of platelet function, coagulation factor activity
and drug metabolism
▪ Exacerbates postoperative bleeding, prolongs neuromuscular
blockade, and may delay awakening
▪ Prolonged PACU stay
▪ Long Term: increased incidence of myocardial ischemia/
infarction, delayed wound healing, increased perioperative
mortality

61. PONV
▪ Incidence: 10%→80%
▪ Delayed Discharge
▪ Unanticipated Admission
▪ Pulmonary Aspiration
▪ Post-operative discomfort

62. PONV RISK
▪ High Risk Patients
▪ Female
▪ History of Motion
sickness/PONV
▪ Nonsmoker
▪ Intra/Postoperative
opioids
▪ Peds
▪ Other Risk Factors
▪ Obesity
▪ Anxiety
▪ Gastroparesis/ Gastric
distension
▪ GERD
▪ Dehydration
▪ Type of Surgery (eye muscle,
middle ear, laparoscopic,
Breast, Plastics)
▪ Anesthetic Drugs (Volatile
0-2hrs, N2O, NMB Reversal?)
Consensus Guidelines for Managing PONV, Anesth & Analg 7/2003

63. PONV
▪ For every 30 minutes of inhalational
anesthesia, there is a 60% increase in PONV
risk…
Consensus Guidelines for Managing PONV, Anesth & Analg 7/2003

64. PONV
▪ Serotonin (5-HT3) Antagonists (Ondansetron)
▪ Effective when given 30min before end of case
▪ Corticosteroids (Dexamethasone)
▪ Replaced droperidol for 1st line prophylaxis, unknown
mechanism (reduce prostaglandins)
▪ Anticholinergics (Scopolamine)
▪ Antihistamines (Hydroxyzine)
▪ Prokinetic (Promethazine)
▪ Butyrophenones (Droperidol)
▪ Very effective, FDA Warning 6/2001, 6 hour monitoring for
cardiac dysrhythmia (torsades de pointes)

65. Treatment PONV
▪ Low Risk Patients
▪ Dexamethasone prophylaxis
▪ Moderate Risk Patients
▪ Dexamethasone prophylaxis
▪ Serotonin Antagonists
▪ High Risk Patients
▪ Dexamethasone prophylaxis
▪ Seratonin Antagonists
▪ Prokinetic
▪ Very High Risk Patients
▪ Multimodal approach
▪ Aggressive IV Fluid
▪ Combination pharmacotherapy
▪ REGIONAL ANESTHESIA when possible
▪ TIVA
▪ Avoid: Opioids, inhalational agents/N2O, reversal
agents

66. Bleeding Abnormalities
Test Normal Value Abnormality
Platelet Count >150,000 cells/mm3 Dilutional, DIC
Bleeding Time 3-10 min Platelet-inhibiting Rx
Prothrombin Time 12-14 sec DIC, Vit K Def, Liver Dz,
Coumadin
Partial Thromboplastin Time 25-35 sec Factor V and VIII Def,
Heparin, Heophilia
Fibrinogen 200-400 mg/dL DIC
Fibrin Split Products <4 µg/ml DIC
TEG N/A Platelet and clotting factor
deficiencies
Platelet Fct Assay N/A Plt Adhesion & Aggregation

67. Case
▪ You are the PACU resident of the week
and the RN calls re:
▪“My patient in slot 12 isn’t
waking up!”
▪ What else do you want to know?
▪ DDX?

68. Delayed Awakening
▪ Possible explanations…
▪ Pharmacological
▪ Residual Drug Effect (Opioids, BDZ, anticholinergics)
***Most frequent cause
▪ Chemical (Metabolic)
▪ Hypoxemia, Hypercarbia, Hypoglycemia, Electrolyte
abnormalities
▪ Physical
▪ Hypothermia (Temp < 33°C), Air Embolism
▪ Neurologic
▪ Increased ICP, Sz/Postictal, Hysteria?

69. Delayed Awakening
▪ Evaluation
▪ VITAL SIGNS!!!
▪ Neurologic Exam
▪ ABG (oxygenation and ventilation)
▪ Additional labwork
▪ Electrolytes, glucose, etc..
▪ Radiographic procedures (CT)

70. Delayed Awakening
▪ Analgesic
▪ Opioids → Naloxone (20-40 µg increments)
▪ Short acting, reversal of analgesia, hypertension, arrhythmias, delerium
▪ Anesthetic - Hypnotic
▪ Benzodiazepines → Flumazenil (0.2mg IV over 15
sec, 0.3mg IV over 30 sec, 0.5mg IV over 30 sec) Side effect/Risk of
seizures
▪ Akinetics
▪ Muscle Relaxants → Neostigmine

71. Modified Aldrete Score D/C Criteria

72. QUESTIONS?