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Immediate Issues
AirwayPneumothorax, airway obstruction, hematoma
BreathingHypoventilation, PE, hypoxemia
CirculationHypotension/hypertension, MI, arrhythmias, CHF, cardiac tamponade
Endocrine/metabolicSIRS/sepsis, adrenal insufficiency, thyroid issues, anaphylaxis, residual anesthetic effects
MiscellaneousPONV, injuries, altered mental status/postoperative cognitive dysfunction

PONV 9.8%, upper airway obstruction 6.8%, and hypotension 2.8% are the most common.

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Airway and Respiratory Issues
Upper airway obstructionHypoventilationHypoxemia
Loss of pharyngeal muscle toneResidual anesthetics or muscle relaxantsAtelectasis, diaphragmatic injury/paralysis
Residual muscle relaxationPostoperative opioids, splinting due to painAspiration
Airway edema/traumaObesity, OSAAsthma/COPD exacerbation
SecretionsPremature infants/neonatesALI/ARDS
LaryngospasmTight abdominal binder/abdominal compartment syndromePTX, pleural effusion
VC paralysis, arytenoid dislocationPneumonia
Foreign bodyCHF, fluid overload

Diagnosis and Management (General)

  • Assess airway, breathing, and circulation
  • Deliver increased FiO2; increase flow rate; consider NRB or shovel mask to goal of SaO2 93–97% (Pao2 80–100 mm Hg)
  • Consider jaw thrust, chin lift, oral/nasal airway placement, or positive-pressure ventilation
  • Review history, OR and postoperative course, fluids and medications administered
  • Consider noninvasive ventilation (CPAP or BiPAP) or intubation
  • Consider ABG, chest x-ray

Management of Specific Conditions

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Common Respiratory Issues in PACU
ConditionDiagnosisSuspected causeTreatment
  • Inadequate ventilation for sufficient gas exchange (PaCO2 high and respiratory acidosis)
Residual muscle relaxantAdminister ACh inhibitor
Opioid overdoseConsider 20–40 μg naloxone IV
Residual inhaled/IV anestheticArouse patient
Tight abdominal binderRelease binder
  • Reposition patient
Splinting (due to pain)Pain control
Premature infants/neonatesAvoid opioids, alternative techniques
Upper airway obstruction/stridor
  • Edema/trauma, VC paralysis, arytenoid dislocation
  • Secretions (blood/fluid)
  • (Suspected) foreign body
  • Humidified air, steroids, racemic epinephrine aerosol
  • Suction secretions/glycopyrrolate (drying agent)
  • Reintubation for severe edema/trauma
  • ENT consult for VC paralysis/arytenoid dislocation/foreign body removal
Asthma/COPD exacerbation
  • Wheezing on auscultation
  • Albuterol/Atrovent nebulizers, steroids, cromolyn sodium, aminophylline, epinephrine as last resort
  • CPAP/BiPAP, reintubation for severe bronchospasm
  • Involuntary tightening laryngeal constrictor muscles and vocal cords
  • Risk factors: young age, URI, GERD, OSA/obesity, ENT surgery
  • Positive-pressure ventilation
  • If severe propofol (10–20 mg) or succinylcholine (0.1 mg/kg)
  • Watch for negative pressure pulmonary edema (4% patients)
  • Decreased breath sounds, opacification on CXR
  • Incentive spirometry
  • Reposition patient
  • Inhaled N-acetylcysteine, chest PT
Pulmonary embolism
  • ECG (S1Q3T3)
  • Lower extremity Doppler
  • CT angiogram of chest
  • VQ scan (if high probability)
  • Cautious fluids, invasive monitoring, consider inotropes/pressors
  • Consider anticoagulation, IVC filter
  • Consider embolectomy/lysis
  • Transfusion-related ALI (TRALI)
  • Acute respiratory failure without cardiac failure
  • Bilateral fluffy infiltrates on CXR
  • ALI Pao2/FiO2 ratio <200 versus ARDS <300
  • Lung-protective ventilation (tidal volume 5–7 mL/kg)
  • Treat underlying cause
Pneumothorax/hemothorax, pleural effusion
  • CXR diagnostic
  • Needle decompression, chest tube
  • Surgical exploration if large hemothorax
Anxiety stridor (Munchausen stridor)
  • Episodic inspiratory stridor with normal flow loops
  • Risk factors: female, anxiety, GERD, type A personality
  • Patient education, ...

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