Download Recognizing Post-Op Distress - Vanderbilt University Medical Center

5/3/2011
Recognizing Post-Op
Distress
First, Do No Harm
• Recognizing early symptoms and signs
• Putting the pieces together
• Case
C
studies
t di
Craig Rooks, BS RRT
Manger/Educator
Respiratory Care, Vanderbilt University Hospital
Barbara Gray, BSN, RN
Quality Consultant
Trauma PCC, Vanderbilt University Hospital
Oxygen Transport Cycle
• Gas exchange − lungs
• Delivery of oxygen − cardiac output
• Consumption
p
of oxygen
yg − tissues
Oxygen and CO2 Metabolism
CO2
Ventilation
O2
Metabolism
CO2 production
Adequate Oxygenation
O2 consumption
Inadequate Oxygenation
SaO2
Hb
CO
SUPPLY
Tissue
Ti
.
VO2
DEMAND
.
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Hypoxia and Hypoxemia
• Hypoxia
– Low oxygen
• Oxygen supply inadequate to meet tissue
d
demands
d
Hypoxemia: Patients at Risk
• Hypoxemia
– Low O2 content in blood
• Low oxygen saturation in the blood
Who’s at Risk for Hypoxemia?
• Patients with…
– Airwayy compromise
p
from secretions or
swelling
– Central or obstructive sleep apnea, either preexisting or exacerbated by anesthesia.
– Procedural sedation
Who’s at Risk for Hypoxemia?
• Postoperative Patients
– Residual effects of anesthesia − rebound in REM sleep
– Pain-inhibited respiratory movements
– Analgesic-induced respiratory depression
– Abdominal and thoracic surgeries
– Episodic hypoxemia up to five nights postoperatively
loss of protective reflexes
depressed respiratory drive
Occurrence of Postoperative Hypoxemia
Post midline abdominal surgery
Postoperative Hypoxemia
Post major abdominal and peripheral surgery
• Study of 69 patients
• Total desaturations (SpO2 < 90% and 88%) were recorded by RNs x 48 hr
• Study of 214 postoperative patients
• Results:
• All patients were receiving narcotic analgesia
• 9 hypoxemic events were charted by nurses
• Monitored for 24 hrs
• 1706 hypoxemic events on monitor
– 1213 events <90%; 493 events <88%)
Curry JP, Hanna CM. Man versus Machine.
Anesthesiology. 2002;96:A1173.
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Postoperative Hypoxemia
Post major abdominal and peripheral surgery
Postoperative Hypoxemia
Post major abdominal and peripheral surgery
SpO2 < 90%
Prostate
# of Pts (96)
• Results
– 3959 desaturation events obtained from
monitor memory
– 23 hypoxemic events noted in patient
charts.
Curry JP, Hanna CH. Comparison of Postoperative Hypoxemia in Major
Peripheral Surgery Patients. 2003 ASA Meeting Abstracts. A-1306
Hips
(41)
# of Incidences
265
1510
2184
% of Patients
78
76
83
Avg. Duration
35.02
59.76
75.16
Curry JP, Hanna CH. Comparison of Postoperative Hypoxemia in Major
Peripheral Surgery Patients. 2003 ASA Meeting Abstracts. A-1306
Who’s at Risk for Hypoxemia?
Who’s at Risk for Hypoxemia?
• Elderly, pediatric and neonatal patients
• Patients in non-critical care settings
– Pulmonaryy reserve often decreased
• Obstetric patients
Knee
(77)
– General medical-surgical
g
care floors
Increasing acuity
– Diminished lung reserve
Patient assessment less frequent than ICU
– Pain during labor and delivery can induce
Higher nurse-patient ratio than in ICU
changes in respirations
– Response to epidural
Cavouras C. Nurse staffing levels in American hospitals: A 2001 report. Journal of Emergency Nursing. Volume 28, Issue 1, pages 40-43.
Stéphane Hugonnet, Ilker Uçkay and Didier Pittet. Staffing level: a determinant of late-onset ventilator-associated pneumonia.
http://ccforum.com/content/11/4/R80
Abner, Celethia M. Increasing critical care skills of non-critical care nurses. Journal for Nurses in Staff Development. May/June
2000;16(3):124-130.
Who’s at Risk for Hypoxemia?
• Patients with acute or chronic cardiopulmonary disease
Hypoxemia: Consequences
– Heart failure or pprevious Myocardial
y
infarction
– COPD
• Technology-dependent patients
– Oxygen-dependent
– Ventilated
– Tracheostomized
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Consequences of Hypoxemia
Physiological
Consequences of Hypoxemia
•
•
•
•
Physiological
Morbidityy
Mortality
Economic
• Impaired cerebral function
– Short-term memory loss
– Confusion
– Cognitive dysfunction
Rosenberg AL. Patients readmitted to ICUs: A systematic review of
risk factors and outcomes. Chest. 2000;118(2):492-502.
MedlinePlus. Sepsis (accessed online)
Http://www.nlm.nih.gov/medlineplus/ency/article/000666.htm
Factors That Increase Risk:
Consequences of Hypoxemia
Physiological
Patient:
– Dysrhythmia,
y y
usuallyy fast rate
• Increased Acuity
• OSA
• Comorbidities
– ST changes
Clinician:
• Myocardial ischemia
• Sleep Deprivation
• Charting Responsibilities
• Increased Nurse:patient ratios
• Compromised wound healing
• Decreased resistance to infections
Rosenberg AL. Patients readmitted to ICUs: A systematic review of
risk factors and outcomes. Chest. 2000;118(2):492-502.
FACEBOOK
Vanderbilt Data
Number of Calls 2010
900
800
700
600
500
400
300
200
100
0
892
128
RRT Calls-892
FIRRT Calls-14
Code Calls-128
14
Total Calls 2010
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2010 Calls by Team
Triggers for RRT in 2010
2010 Triggers for RRT calls
Multiple
Triggers
450
400
350
300
250
200
150
100
50
0
Neuro
CVICU
MICU
SICU
126
Respiratory
96
63
247
Staff
62
Concern
Cardiac-406
Staff
Concerned-62
Neurologic-63
441
438
Respiratory-247
Cardiac
Team Calls 2010
406
RRT vs. Non-ICU Stats per 1,000 discharges-all areas
(older data)
Disposition of Pt after RRT Call 2010
700
RRT vs STATs per 1,000 Discharges
March 2007 - April 2009
600
Multiple
triggers-96
RRT
STAT
25
500
20
400
625
300
296
200
Stayed on Home UnitUnit
625
Transfer to Step-down41
Transfer to ICU-296
15
10
5
41
100
0
0
Disposition of Patient after Call
Case #1:
Case #1:
• You are covering a 46yo surgical patient <12 hour post-op.
• Patient has PCA, scheduled pain meds, and PRN pain
meds, pain = 5/10
Time
19:15
21:00
23:30
23:30
RR
Sp02/02
LOC
100%/2L Drowsy but following bnc
Commands
14
78
105/59 95%/2L bnc
Drowsy
8
94
94/50 80%/2L Unresponsive
bnc
would open eyes and inhale once each time instructed to do so, would immediately go back to sleep. Rapid Response Called
18
HR
64
BP
110/71
• RRT called at 23:30
• Patient placed on NRB and given 2 doses
of Narcan.
Narcan
• Transferred to ICU
• Eventually discharged
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Case #2:
• You are covering a general care surgical floor
when you are notified about 53yo male, 24
hours post-op, who presents as follows:
Time
RR
HR
BP
Sp02/02
LOC
17:00
25
120
120/65
<90%/2L NC
22:15
28
126
<90%/50% Venturi mask
Easily reoriented
Progressive Confusion
24:00
>35
130
40% CPAP/92%
Confused
RRT called
110/60
Case #2:
• RRT called
• Patient transferred to ICU and set up
p on
BiPAP and subsequently intubated after
one hour.
• Patient discharged to home after ICU stay.
Case #3:
•
•
Mr. T is a 52yo male with hx of hypertension, diabetes, pancreatic
cancer, currently admitted with abdominal/back pain. A
Pancreaticoduodenectomy (Whipple) was done 3 days ago.
Time
RR
HR
BP
SpO2/ O2
04:30
16
108
96/58
94%/ 2L
09:00
20
111
88/49
90%/ 4L
13:30
20
109
104/69
91%/ 6L
17:45
22
108
114/77
84%/ 6L
Case #4:
Case #3:
• Pt. c/o sudden dyspnea, changed to 50% venti
mask, then NRB, 40mg Lasix given, physician
att bedside
b d id
• 18:50 RRT called for low sats…
• Pt. was transferred to MICU where he was
intubated upon arrival.
Case #4:
• You have a 63y/o morbidly obese female post laparoscopic
gastric bypass. Following is first set of Vital Signs:
Time
RR
HR
BP
Sp02/o2 LOC
20:30
18
95
103/61
97%/5L awake
bnc
20:45
Sp02 drops to 80% when patient falls asleep
Sp02 improves when patient is awake
• Patient discharged <48 hours after event
• An estimated 18 million Americans
have sleep apnea
Family member states that patient uses home CPAP
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Case # 5:
80 yo male with COPD admitted for dyspnea and cough
Background/history: A-fib, hypertension, diabetes, home
oxygen, home CPAP, OSA
Time
20:30
RR
26
HR
115
BP
182/102
SpO2/O2
96%/ 3L
00:43
26
130
192/108
92%/ 4L
03:00
24
108
152/100
93%/ 6L
06:20
35
113
182/80
89%/
50%vm
Case #5:
•RRT called for low SpO2, labored breathing,
•↑ HR
•Patient transferred to MICU
•RT to initiate BiPAP
Key Points:
• Trending Vital Signs
• Patients receiving sedation: not everyone reacts
the same (tolerance)
• Certain
i comorbidities
bidi i place
l
patient
i at higher
hi h
risk: age, weight, airway disease, cardiac
disease, diabetes, etc.
• Home medications
• Consider intra-op trends/parameters
Questions???
Thank You!
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