TRA18 • Trauma Special Offer

Table of Contents

TRA18 • Trauma Special Offer

How to Receive Credit

NetCE 15 Hour Course #90743 • Transport Methods for Critically Ill Patients

90743 • Transport Methods for Critically Ill Patients

1. INTRODUCTION

2. MODES OF TRANSPORT

3. TRANSPORT PHYSIOLOGY

4. THE TRANSPORT PROCESS

5. STABILIZATION FOR TRANSPORT

6. STABILIZATION OF SPECIFIC PATIENT POPULATIONS

7. DETAILS INVOLVED IN THE TRANSPORT OF PATIENTS

8. PRINCIPLES OF TRANSPORT

9. MEDICAL-LEGAL ISSUES

10. SUMMARY

11. INTERNET RESOURCES

Works Cited

Works Consulted

Evidence-Based Practice Recommendations Citations

NetCE 15 Hour Course #30763 • Postoperative Complications

30763 • Postoperative Complications

1. INTRODUCTION

2. ASSESSMENT OF THE POSTSURGICAL PATIENT

3. GLOBAL COMPLICATIONS

4. COMPLICATIONS WITHIN BODY SYSTEMS

5. COMPLICATIONS IN SPECIFIC PATIENT POPULATIONS

6. CONCLUSION

7. GLOSSARY OF TERMS

Works Cited

Evidence-Based Practice Recommendations Citations

TRA18 • Trauma Special Offer

Susan Engman Lazear, RN, MN

www.netce.com

Copyright © 2024 NetCE, All rights reserved.

TRA18 • Trauma Special Offer

Expiration Date: 02/28/2022

How to Receive Credit

To complete this Special Offer for continuing education credit please go to http://www.netce.com/specials in your browser.

For assistance with receiving continuing education credit, please contact us at help@netce.com.

90743 • Transport Methods for Critically Ill Patients

Susan Engman Lazear, RN, MN

www.netce.com

Copyright © 2019 NetCE, All rights reserved.

Healthcare professionals are an integral part of the transport system, stabilizing patients prior to transport, providing care in transport and ensuring the safety of the patient throughout the transport process. This course will provide information on the types of transport available, transport physiology (those stressors that impact the patient in transport), transport regulations, stabilization for transport, care in transport, and the general principles of transporting patients, including both safety and medical-legal issues. All healthcare professionals involved in caring for sick or injured patients must be aware of all of these concepts in order to provide optimal care.

Table of Contents

90743 • Transport Methods for Critically Ill Patients

Course Overview

Audience

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

1. INTRODUCTION

HISTORY OF TRANSPORT

2. MODES OF TRANSPORT

3. TRANSPORT PHYSIOLOGY

HYPOXIA

GAS EXPANSION

DEHYDRATION

DECREASED TEMPERATURE

ACCELERATION AND DECELERATION FORCES (G FORCES)

PROLONGED IMMOBILIZATION

MOTION SICKNESS

NOISE

VIBRATION

DECOMPRESSION SICKNESS

4. THE TRANSPORT PROCESS

TRANSPORT REGULATIONS

INTERFACILITY TRANSFERS

5. STABILIZATION FOR TRANSPORT

AIRWAY AND BREATHING

HEMODYNAMIC STABILIZATION

CENTRAL NERVOUS SYSTEM STABILIZATION

MUSCULOSKELETAL STABILIZATION

EMOTIONAL STABILIZATION AND PSYCHOSOCIAL SUPPORT

BASELINE DIAGNOSTIC STUDIES

DOCUMENTATION

6. STABILIZATION OF SPECIFIC PATIENT POPULATIONS

NEUROLOGICALLY COMPROMISED PATIENT

RESPIRATORY PATIENT

CARDIOVASCULAR PATIENT

BURN PATIENT

MULTIPLE TRAUMA PATIENT

PEDIATRIC PATIENT

ELDERLY PATIENT

HIGH-RISK OBSTETRICAL PATIENT

7. DETAILS INVOLVED IN THE TRANSPORT OF PATIENTS

GENERAL CARE IN TRANSPORT

COMMUNICATION

MEDICAL CONTROL

SPECIFICS OF GROUND TRANSPORT

SPECIFICS OF FIXED-WING TRANSPORTS

SPECIFICS OF ROTOR-WING (HELICOPTER) TRANSPORTS

TRANSPORT EQUIPMENT

8. PRINCIPLES OF TRANSPORT

SAFETY ISSUES

9. MEDICAL-LEGAL ISSUES

COBRA/EMTALA IMPACT

MANAGEMENT ISSUES

FUTURE DEVELOPMENTS

10. SUMMARY

11. INTERNET RESOURCES

Works Cited

Works Consulted

Evidence-Based Practice Recommendations Citations

90743 • Transport Methods for Critically Ill Patients

Education Category. Medical / Surgical

Release Date. 08/01/2019

Expiration Date. 07/31/2022

Course Overview

Healthcare professionals are an integral part of the transport system, stabilizing patients prior to transport, providing care in transport and ensuring the safety of the patient throughout the transport process. This course will provide information on the types of transport available, transport physiology (those stressors that impact the patient in transport), transport regulations, stabilization for transport, care in transport, and the general principles of transporting patients, including both safety and medical-legal issues. All healthcare professionals involved in caring for sick or injured patients must be aware of all of these concepts in order to provide optimal care.

Audience

This course is designed for all healthcare professionals involved in the transport of critically ill patients, including physicians, physician assistants, and nurses.

Course Objective

The purpose of this course is to provide information on the types of patient transport available, transport physiology, transport regulation, stabilization for transport, care in transport, and the general principles of transporting patients, including both safety and medical-legal issues, in order to facilitate better patient care.

Learning Objectives

Upon completion of this course, you should be able to:

1. Compare the advantages and disadvantages of ground, fixed-wing, and helicopter transport.

2. Evaluate physiologic changes that occur during transport and list interventions to limit patient compromise.

3. Describe the current federal requirements and regulations in regard to transporting the ill or injured patient.

4. List, in order, the appropriate steps in arranging an interfacility transport.

5. Identify stabilization procedures to be undertaken for all patients requiring transport.

6. Describe the emotional impact of transport on the patient and/or the family and list interventions to provide psychosocial support for these individuals, taking into consideration cultural and linguistic variables.

7. List the baseline diagnostic studies to be performed prior to transport, if time and patient condition warrant their performance.

8. Cite physiologic changes that occur during transport and impact the neurologic, respiratory, and cardiovascular systems.

9. Summarize special considerations for transport of burn and multiple-trauma patients.

10. Identify the problems that may occur during transport of the pediatric patient.

11. Identify the stressors of transport that impact the elderly patient and cite how to best stabilize the patient to limit these complications.

12. Describe the impact of transport on the pregnant patient and her fetus and how these problems can be managed.

13. Describe the steps in caring for a patient in transport.

14. Describe how transport impacts the choice and use of biomedical equipment.

15. List actions to take to ensure the safety of the crew, the patient, and the personnel on the ground when performing both a helicopter and a fixed-wing transport.

16. Cite the medical-legal requirements of providing care to a patient outside of a hospital system.

Faculty

Susan Engman Lazear, RN, MN, received her undergraduate education at the Walter Reed Army Institute of Nursing in Washington, D.C. After completing her BSN, she served as an Army Nurse at Letterman Army Medical Center in San Francisco for four years. She then attended the University of Washington School of Nursing and received a Master’s in Nursing, specializing in Burn, Trauma and Emergency Nursing. After receiving her MN, she started Airlift Northwest, the air ambulance service based in Seattle which serves the entire Northwest region, including Alaska. Mrs. Lazear left the air ambulance service to start her own nursing education and consulting business, Specialists in Medical Education. For the past 20 years she has been teaching emergency nursing courses throughout the country. She lives in the Seattle area. Mrs. Lazear continues to teach and publish. She is both an editor and contributing author of Critical Care Nursing, published by W.B. Saunders Company, in June of 1992. She served as an author and reviewer of the Emergency Nursing Core Curriculum 6th Edition, published by W.B. Saunders Company in 2007. She has been named to the Who’s Who in American Healthcare list annually since 1992.

Faculty Disclosure

Contributing faculty, Susan Engman Lazear, RN, MN, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planners

Ronald Runciman, MD

Jane C. Norman, RN, MSN, CNE, PhD

Division Planners Disclosure

The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

1. INTRODUCTION

Stabilization and transporting patients when the needs of the patient surpass the available resources of a facility is now common occurrence. Legislation requires that patients receive the optimum care available to them, thus requiring the transport of patients to facilities that can provide this type of care. Healthcare professionals are an integral part of the transport system whether they are stabilizing patients prior to transport, providing care in transport, or ensuring the safety of the patient throughout the transport process. This course will provide information on the types of transport available, transport physiology (e.g., the stressors that impact the patient in transport), transport regulations, stabilization for transport, care in transport, and the general principles of transporting patients, including both safety and medical-legal issues. All healthcare professionals involved in caring for sick or injured patients should be aware of all of these concepts in order to provide optimal care.

HISTORY OF TRANSPORT

Transport of the sick or injured patient from one location to another is not a new concept. For all of recorded history, patients have been moved so that they could receive medical treatment. Soldiers wounded on the battlefield have been transported in moving conveyances ranging from horse-drawn carts to purpose-built aircraft. The first soldiers transported by air were flown in hot air balloons during the Prussian siege of Paris in 1870. Throughout the 20th century, transport methods developed slowly and, at times, haphazardly. However, during the late 1960s and early 1970s, Congress enacted numerous pieces of legislation addressing emergency medical care and transport. These laws were the impetus to develop sophisticated transport systems. Since that time, transporting of patients has developed into a subspecialty of emergency medicine, involving physicians, nurses, paramedics, respiratory therapists, and other prehospital care providers. Transferring a patient in a safe and efficient manner is now considered essential in the provision of medical care.

2. MODES OF TRANSPORT

Transport of patients occurs primarily in two distinct environments: on the ground by ambulance or in the air by either a rotor-wing vehicle (helicopter) or a fixed-wing vehicle (airplane). Air and ground transport each have advantages and disadvantages; the decision whether to use air or ground transport should be made on the basis of many factors. Consideration of out-of-hospital time, weather, terrain, work space, equipment, personnel, and proximity of a landing site will assist the transferring team in making an informed decision as to how to best meet each individual patient's needs.

Ground transport occurs most often in a modular type vehicle that can easily accommodate two supine patients and a full crew. Access to the patient is excellent and advanced life support measures can be easily performed. Larger ambulances can accommodate larger pieces of equipment including infant isolettes, ventilators, and intra-aortic balloon pumps. The level of care administered during the transport varies with the level of training of the transport personnel, varying from basic life support (BLS) to advanced life support (ALS). In choosing an appropriate transport vehicle, the referring physician is required to choose a vehicle in which the level of care does not diminish during the transport itself.

Ground transport is the cornerstone of the emergency response system in the United States. Ground ambulances are accessed by the public through the 911 system and provide rapid stabilization of ill or injured patients. In large urban areas with well-developed prehospital care systems, the time-to-patient is less than 10 minutes. However, as the population base expands into rural areas, the time-to-patient tends to lengthen, delaying access to medical care. To reduce the patient's out-of-hospital time, air ambulances have been developed to augment ground transport programs, providing rapid transfer.

Ground ambulance transport is an efficient and appropriate method of transport for most ill and injured patients in this country. The number of ground transports increases annually and the appropriateness of these transports is unquestioned. However, there are instances in which ground transport is at a disadvantage. Adverse weather conditions can impact the vehicle's ability to traverse certain terrain. At the same time, this adverse weather can prevent air ambulances from flying, leaving ground transport as the only viable option. Time-in-transit is another drawback of ground transport. Some critically ill or injured patients cannot withstand the stressors of transport and the shorter the out-of-hospital time, the better that patient's chance for survival. Finally, when choosing to utilize a ground ambulance, the needs of the community should be examined. Some isolated rural areas have only a single ground ambulance to service a largely scattered population base. If this vehicle is taken out of service for an interfacility transport, the people of the community are temporarily left without the medical coverage they have come to expect.

Air transport should be considered an adjunct to, not a replacement for, ground transport. There are inherent dangers in transporting by air, and it is an expensive alternative. Many third-party providers are withholding reimbursement for flights, which are considered nonemergent. The advantage of fixed-wing transport is the ability to travel long distances at speeds between 250 and 570 miles per hour. Care is usually provided in a pressurized cabin with sophisticated on-board medical equipment. Many aircraft utilized for air transport of patients have the capability of transporting multiple patients, and in some instances, family members are allowed to accompany the patient. All-weather navigational equipment allows for the transfer of patients during inclement weather. Many of the dedicated aircraft utilized in air transports have been referred to as "flying ICUs."

Fixed-wing transport requires suitable airfields to ensure the safety of the crew and patient. Accessibility to such fields may be a problem in isolated areas. Optimally, a 5,000-foot paved runway located near the site of the patient would erase the disadvantages of air transport. However, because hospitals are located a considerable distance from most airfields, ground transport is utilized at the beginning and the end of the air transport. (Note: A unique situation exists in Anchorage, Alaska, where a regional referral medical center is located on the edge of an appropriate airfield and the patient can be off-loaded from the plane and wheeled directly into the hospital. This is far from the norm.) The patient should be moved in and out of the aircraft to a waiting ground ambulance and then transported from the referring hospital or to the receiving hospital. This increases the likelihood of the dislodgment of tubes, lines, etc. There is an additional cost associated with this supplemental ground transport.

Rotor-wing vehicles provide rapid point-to-point transfers. Helicopters are capable of reaching most areas and can bypass difficult terrain. Landing zones can be made at or near the site of the patient to prevent lengthy ground transport times. Most helicopters operate within a 150-mile radius of their base station to allow for routine flights without refueling. The type of helicopter utilized by a transport program is determined by a number of factors. Most programs now rely on twin-engine helicopters for their enhanced performance and safety records. Certain helicopters perform better at altitude; they are utilized in areas of high terrain, such as in the Rocky Mountains or in the Swiss Alps. The highest helicopter rescue was performed in 2010 at 23,240 feet (density altitude) for injured climbers on the Kamet glacier in the Himalayas. In 2013, a simulated rescue was performed at 25,590 feet on Mt. Everest; however, the practical limit for safe rescue operations is generally agreed to be 23,000 feet [6].

The single largest disadvantage of helicopters is their dependence upon certain minimum weather conditions; if these conditions are not met, the weather can cause delay or cancellation of the flight. Helicopter cabin size often restricts access to the patient once the patient has been loaded into the helicopter. This limited access reduces the number of in-flight interventions possible. Weight limitations restrict the number of passengers and the amount of equipment on board. When transferring a patient by rotor-wing vehicle, comprehensive stabilization of the patient is required prior to departure.

As healthcare dollars become tighter and legislation mandates transport of patients to better-equipped facilities, those caring for patients who need transport should be cognizant of the advantages and disadvantages of the modes of transport. As air ambulance programs continue to proliferate in this country (although the number of programs has leveled off in the last few years), the preparation to choose between ground, helicopter, or fixed-wing transport will be important.

3. TRANSPORT PHYSIOLOGY

Exposure to environmental factors occurs during both ground and air transport. Some of the stressors are unique to air transport; for example, atmospheric changes occur when the aircraft's altitude changes. The problems that develop depend on vehicle design and configuration, motion of the transport vehicle, the patient's condition, or a combination of factors. Many of these stressors are detrimental to the patient's condition; however, with proper nursing care before and during the transport, these harmful effects can be minimized or eliminated.

Transport vehicles are designed according to different principles. These design specifics can impact the stressors that a patient encounters. Ground ambulances should travel as the road lies. This causes multiple forward, reverse, and lateral forces on the patient and the crew. These forces are greatly minimized in both fixed-wing and helicopter transports; however, the forward and reverse forces are momentarily much greater when an airplane is taking off or landing.

The following ten problems occur during transport. The first four are a result of changes in atmospheric pressure; therefore, these are only encountered in air transport.

HYPOXIA

Four types of hypoxia can occur to impact the oxygenation status of the patient transported by air. The physiology of these four types will be reviewed, followed by a discussion of the manifestations of hypoxia and interventions that can be instituted to minimize or prevent these harmful effects.

Hypoxic Hypoxia

Hypoxic hypoxia, also known as altitude hypoxia, occurs when changes in atmospheric pressure are encountered. As an aircraft (both fixed-wing and rotor-wing) ascends in altitude, the partial pressure of oxygen (PO_2) decreases, causing a decreased diffusion gradient for the oxygen molecule to cross the alveolar membrane. Table 1 shows the effects of altitude on the PO_2.

Table 1: EFFECTS OF ALTITUDE ON PARTIAL PRESSURE OF AMBIENT HUMIDIFIED OXYGEN

Altitude (feet)

Atmospheric Pressure (mm Hg)

Partial Pressure of Oxygen (mm Hg)

0

760

150

500

746

147

1,000

733

144

1,500

720

141

2,000

707

139

2,500

694

136

3,000

681

133

3,500

669

131

4,000

656

128

4,500

644

125

5,000

632

123

5,500

621

121

6,000

609

118

6,500

598

116

7,000

586

113

8,000

564

109

9,000

543

104

10,000

523

100

Source: Compiled by Author

Simple calculation of the diffusion gradient is accomplished by utilizing the following formulas:

(Atmospheric Pressure - Water Pressure) x

Oxygen Percentage = PO_2

and

Alveolar PO_2 - Venous PO_2 =

Diffusion Gradient

Assuming that the water pressure is equal to 47 mm Hg, the PO_2 at sea level would be approximately 150 mm Hg [(760-47) x 0.21 = 150]. At an altitude of 6,000 feet the calculated PO_2 would be 118 mm Hg [(609-47) x 0.21) = 118].

The decrease in PO_2 that occurs in the respiratory tree is approximately 45 mm Hg. Therefore, at the alveolar level, the partial pressure of arterial oxygen (PaO_2) at sea level would be approximately 105 mm Hg (150-45) and the PaO_2 at 6,000 feet would be approximately 73 mm Hg (118-45). The PO_2 of venous blood is approximately 40 mm Hg. Therefore, the diffusion gradient at sea level is equal to 65 mm Hg (105-40) and at 6,000 feet this gradient is 33 mm Hg (73-40). Patients with congestive heart failure and respiratory distress syndrome, among others, would be severely compromised when this drop in the diffusion gradient occurs.

Most fixed-wing aircraft utilized in air transport are pressurized, which allows for a comfortable cabin atmosphere when flying at higher altitudes. Generally, the lower the plane is flying, the lower the cabin altitude that can be achieved. This ability to maintain a physiologically comfortable environment within the aircraft minimizes the effects of altitude changes upon the patient. Rotor-wing vehicles are not pressurized, so these atmospheric changes impact the patient whenever the helicopter ascends. Therefore, the patient transported by helicopter may be at greater risk than those patients transported by fixed-wing aircraft. However, altitude gains are usually minimal and most patients are able to tolerate these changes [1].

Histologic Hypoxia

Histologic hypoxia occurs in patients whose hemoglobin molecule is bound by molecules other than oxygen. There is an absence of oxygen at the tissue level leading to severe hypoxic events. Causes of histologic hypoxia include carbon monoxide poisoning, cyanide poisoning, as well as heavy smoking [2]. As an example, a burn patient who suffers from carbon monoxide poisoning requires air transport to a burn center. This patient is transported by air and encounters the effects of hypoxic hypoxia in addition to histologic hypoxia. The patient is at severe risk of sustaining life-threatening low PaO_2 levels.

Anemic Hypoxia

When a patient has an inadequate amount of circulating hemoglobin, he is said to have anemic, or hypemic, hypoxia [2]. Causes of anemic hypoxia include anemias and hemorrhage. A drop in hemoglobin to 10% or a hematocrit of less than 30 is most often associated with anemic hypoxia. These patients should be monitored for an adequate oxygen level to prevent further compromise in the patient's status. A commonly utilized monitoring technique is oxygen saturation. However, it is important to remember that oxygen saturation is only a measurement of the hemoglobin saturation. As an example, a patient with an oxygen content of 19 volume percent with a 20 volume percent capacity will have an oxygen saturation of 95%. This same patient could lose half of his blood volume so that the oxygen capacity would be 10 volume percent. If his oxygen content is 9.5 volume percent, his oxygen saturation is also 95%.

Stagnant Hypoxia

Stagnant hypoxia is caused by inadequate circulating hemoglobin. Different from other states, the patient with stagnant hypoxia has an adequate supply of oxygen and hemoglobin; however, it is not adequately circulated [2]. Examples of patients with a predisposition to stagnant hypoxia include those with low cardiac outputs (heart failure), hypothermic patients, and patients in hypovolemic shock. Additionally, the stressors of acceleration and deceleration forces (to be discussed at length later in this course) further compromise circulatory status in these patients.

Manifestations of Hypoxia

Signs and symptoms of hypoxia include changes in vital signs, tachycardia, pupillary constriction, confusion, disorientation, and lethargy. Insidious and gradual in development, these signs may also be caused by a number of other illnesses and injuries, making the diagnosis of hypoxia more difficult. Astute observation of the patient is necessary to detect and correct the problems of hypoxia.

A great deal of research has been performed upon the effects of hypoxia on normal individuals. The military uses this information to establish guidelines for pilot performance. This research demonstrates what is referred to as time of useful consciousness (Table 2). This is the time in which a person subjected to a hypoxic environment can function to protect themselves from the harmful effects of hypoxia. Most commercial aircraft and aircraft utilized in air transport fly below 41,000 feet, indicating that the pilot will have a little less than 300 seconds to protect themselves from these detrimental effects in the event of cabin depressurization. Utilizing this information, the Federal Aviation Administration (FAA) has set requirements for oxygen use among pilots and occupants that state that oxygen use is mandatory for pilots when cabin pressure altitude is 12,500 to 14,000 feet for durations of more than 30 minutes or any duration at cabin pressure altitudes greater than 14,000 feet, and that oxygen must be available for all persons on board if the cabin pressure altitude is greater than 15,000 feet [3]. In a pressurized aircraft with two pilots at the controls, pilots must have their oxygen masks readily available to them in the cockpit (quick-donning type, ready within 5 seconds, and able to be placed on face with one hand) if flying at an altitude between 35,000 and 41,000 feet [3]. If at any time there is only one pilot at the aircraft controls and the altitude is above 35,000 feet, he or she must wear and use supplemental oxygen until the second pilot returns to his/her controls.

Table 2: TIME OF USEFUL CONSCIOUSNESS (IN NON-PRESSURIZED ENVIRONMENTS)

Altitude (in feet)

Time Frame

Below 18,000

30 minutes

25,000

3 to 5 minutes

30,000

90 seconds

35,000

30 to 60 seconds

Above 40,000

15 seconds or less

Source: Compiled by Author

Interventions

Prevention is the best approach to dealing with possible hypoxia development. Before transporting a patient by air, stabilization measures can be undertaken to help reduce the effects of hypoxia. Supplemental oxygen should be provided. If the patient has previously required oxygen, the oxygen percentage can be increased. This increase in oxygen delivery is performed as a prophylactic, temporary measure, and upon arrival at the receiving institution, the oxygen can be decreased or terminated as the patient's condition warrants.

Proper positioning of the patient combats the effects of hypoxia. The head of the stretcher may be elevated if not contraindicated by the patient's condition. However, in rotor-wing aircraft this elevation is often not possible due to the size of the cabin and placement of the patient within the helicopter.

Patients experiencing anemic hypoxia can be transfused to increase the hematocrit and improve the oxygen carrying capacity of the blood; however, this measure should not cause a delay in commencing the transport. Additional interventions include providing a calm environment while explaining all procedures and noises to the patient. Often, the patient's hypoxia worsens due to anxiety precipitated by the psychologic stressors associated with transport. Monitoring the patient's vital signs and observing for the signs associated with hypoxia will allow the transport personnel to monitor the patient's response to hypoxia. Portable arterial blood gas analysis may be available in certain transport programs; however, machinery does not replace assessment, and astute observation is paramount.

GAS EXPANSION

As an aircraft ascends, atmospheric pressure decreases and gas expands (Boyle's law). Gas expansion can be directly measured; 100 cubic centimeters (cc) of gas at sea level will expand to 130 cc at an altitude of 6,000 feet, to 200 cc at 18,000 feet, and to 400 cc at 34,000 feet. Gas expansion is a potential problem in all transports that ascend, but is especially harmful to patients transported in unpressurized aircraft flying above 12,000 feet.

Air can be present in many places in the body and in support equipment during patient transport, including the pleural space when a pneumothorax is present, air splints, and endotracheal tube cuffs. Pretransport stabilization measures can be instituted to prevent air expansion complications from hampering patient outcomes.

A pneumothorax that is recognized prior to transport should be treated with either a chest tube or, if chest tubes are impractical due to environmental limitations, a flutter valve attached to a one-way valve (Heimlich valve). Endotracheal tube cuffs should be monitored during transport as the air in the cuff will expand. The cuff may be partially deflated on ascent to prevent tracheal damage. (It is important to remember that gas can significantly expand during ascent and then decrease during descent. If air is removed, such as from an endotracheal tube cuff, it should be reinflated upon descent.)

Air splints should have air removed during ascent and replaced during descent. If this simple maneuver is overlooked, the splints become very tight, compromising the patient's circulatory status.

The gastrointestinal (GI) tract contains a great deal of gas. A nasogastric tube placed prior to transport will decrease gas expansion and reduce the risk of vomiting. A patient with a colostomy or ileostomy can have a rectal or nasogastric tube inserted into the stoma to reduce gas expansion in the lower bowel.

The patient may complain of dental pain from dental caries (tooth decay) that have not been managed appropriately. Little can be done during transport to ease the patient's pain except the administration of pain medication. The patient may also complain of ear pain (this is most common among the pediatric population). Expansion of gas trapped in the middle ear can be treated with vasoconstrictor nasal sprays and by assisting the patient with maneuvers to clear their ears. One useful procedure in the pediatric population is to have the child suck. A small child can suck on a pacifier, and if not contraindicated, an older child can have a small amount of liquid through a straw. The sucking motion helps relieve the pressure. Performing the Valsalva maneuver often assists with clearing the middle ear.

Finally, equipment can have gas inside that will expand. Glass intravenous (IV) bottles have air inside, and as the aircraft ascends, the gas expands and the rate of fluid delivery increases. The bottle should be vented in order to achieve proper functioning. However, a safer technique is to utilize plastic IV bags that do not contain air and also do not present a hazard during unexpected turbulence.

Most of the complications of gas expansion occur during fixed-wing transports as the altitude achieved is much higher. However, gas expansion can occur in helicopter and ground transports that traverse high mountain passes. It is essential to perform the interventions described above whenever the transport involves significant changes in altitudes.

DEHYDRATION

A drop in ambient humidity also occurs with an increase in altitude. This loss of humidity is enhanced in a pressurized aircraft; cabin pressurization is achieved by introducing compressed air from the engines, recycling the air, and removing moisture to protect the aircraft and its electronic systems from corrosion. Ambient humidity in a pressurized aircraft after one hour of flying time is less than 5%.

Patients who are dehydrated or diaphoretic are at increased risk for dehydration, causing a further decrease in their circulating volume. A dry environment is also harmful to a patient's respiratory tract, as drying of the mucous membranes and loss of ciliary action can lead to an increased risk of respiratory tract infections.

Providing adequate hydration to the patient during transport can minimize the effects of dehydration. Ensuring adequate circulating volume prior to transport will ensure that the patient is stabilized appropriately. Adding humidification to the oxygen delivery system throughout transport will counter the drying effects of oxygen.

DECREASED TEMPERATURE

The standard lapse rate for temperature is that for each 1,000-foot gain in altitude there is a 2 degree centigrade drop in temperature, until the temperature reaches negative 55 degrees centigrade. The harmful effects of a decreasing temperature arise when the fuselage of the aircraft becomes cold. This cold is transmitted through the cabin walls causing the interior to cool. The coldest area in the aircraft is against the outside walls, where the patient stretcher is usually secured. An unconscious patient will not be able to report being cold and the effects of hypothermia may be subtle. An additional factor that impacts this concept is that the transport personnel are working and producing heat; their body temperature may actually feel warm and, therefore, they do not recognize that the environment has cooled significantly.

Although this problem is greatest during the colder winter months, the effects of the drop in temperature are experienced year-round. A drop in body temperature causes a decrease in the patient's level of consciousness and can produce shivering. The decrease in the patient's level of consciousness can be attributed to a number of factors, including hypoxia, dehydration leading to a decreased circulating volume, and a decreased temperature. Because the transport personnel have limited resources available to them to determine the cause of patient deterioration, they should assume that the problems of transport are compromising the patient and intervene to correct these problems.

Decreased temperature is not solely an altitude-induced problem. During a transport, a patient is subjected to a number of environmental changes. As an example, a patient may be injured at a scene of an accident and not found for a period of time. During this delay in receiving medical care, the patient becomes hypothermic. He is subsequently found, stabilized, and transported by ground ambulance to the nearest facility. During ground transport, the transport personnel heat the interior of the ambulance and work to maintain the patient's body temperature. Upon arrival at the hospital, the staff works to warm the patient. During evaluation of the patient's injuries, the determination is made to transport the patient to a trauma center, which is located 250 miles away. Arrangements for air transport are made and the patient is stabilized for transport. At this point the patient's temperature may be stabilizing; however, he is then transported from the hospital to an ambulance and transported from the ambulance to the aircraft. During air transport the patient again becomes hypothermic due to the decreased temperatures at altitude. Finally, before arriving at the Trauma Center, he is again transferred out of the plane and into another awaiting ambulance. The patient has been subjected to at least seven different environments, and if these transfers occurred in the middle of winter, it is obvious what this can do to impact the patient's condition.

Paramount to preventing temperature changes in patients is awareness of the ambient temperature. Minimizing the patient's exposure during transfer is of utmost importance. Maintaining an adequate supply of linens to warm the patient is helpful. Burn patients are at great risk from environmental changes and may benefit from the use of a rescue (Mylar) blanket. Pediatric and elderly patients are prone to hypothermia, and using a hat will help reduce up to 10% of radiated heat loss [4].

An additional complication that occurs with a decrease in temperature is that air molecules contract when cold. This is the opposite of the effects that occur with an increase in altitude as previously discussed. In a cold environment, air splints may deflate, thereby losing their effectiveness. This is most often encountered when a patient is in air splints and is removed from a warm hospital to the cold air outside. Each time the environmental conditions change, the effects on gas expansion or contraction should be compensated for.

Cold environments also impact IV solutions and medications, most notably those containing mannitol. Solutions stored in the aircraft are quite cool and should be warmed prior to administration. Mannitol may crystallize when cooled, rendering it useless. These solutions should be stored in the warmest spot in the cabin (usually the cockpit) and, if necessary, rewarmed. Warming of IV fluids can be done by utilizing a heat pack that is wrapped around the IV bag and part of the tubing. While this method will not assist in rewarming a hypothermic patient, it will prevent the administration of cold fluids. Mannitol is usually not stored in the aircraft in cold locales; it is considered to be one of the items that is loaded into the aircraft immediately prior to departure.

Time/temperature indicator (TTI) labels that can monitor mean kinetic temperatures, allowing for assessment of potential or real pharmacologic degradation, are used in clinical evaluations. With this type of measurement method, flight crews would be assured that the medications stored onboard the transport vehicle are safe and effective for patient care.

ACCELERATION AND DECELERATION FORCES (G FORCES)

Acceleration and deceleration forces occur in all methods of transport; the severity and angle of these forces varies by vehicle type. Acceleration forces occur on takeoff, climb-out, or when a ground ambulance speeds up. These forces can produce what is known as positive G forces. These forces can be significant enough to cause fluid shifts in severely compromised patients. Blood pools in the dependent areas, most commonly the legs. The effects of positive G forces can produce what is known as "grey-out." This is a phenomenon that occurs when there is an inadequate circulating blood volume to the head, essentially causing the individual to faint momentarily. As soon as normal circulation is established the patient's level of consciousness returns to its previous state.

Deceleration forces occur upon slowing down, stopping, or during a rapid descent. As most patients are positioned in the transport vehicle with their head forward, these forces produce negative G forces, or "red-out," which is a rush of blood to the head. The term red-out was coined when this phenomenon was noted to produce a momentary reddening of the sclera in the eye as intraocular blood volume increased. Negative G forces are most harmful to the patient with increased intracranial pressure. This rush of blood to the cranial cavity causes a sudden, abrupt rise in intracranial pressure and subsequent deterioration in the patient's level of consciousness.

The effects of acceleration and deceleration forces vary with the speed, angle, and duration of the forces. Military pilots are subjected to these forces on a frequent basis and have developed a tolerance to them. These forces are most pronounced in a fixed-wing transport on either takeoff or landing. In certain situations; the pilots have some control over these factors, such as obtaining a slow rate of descent and having a longer landing roll. These issues are discussed with the pilots prior to departure and the pilots will work with the air traffic controllers to try to achieve the maximum benefit for the patients, while working within the constraints of the environment and vehicle performance.

Positioning the patient is crucial to limiting the effects of these forces. In most aircraft the stretcher should be secured with the head forward, requiring that the patient be placed in this position. If the patient can tolerate a head-elevated position, this will limit the abrupt rise in intracranial pressure that occurs during deceleration. Elevating the feet of the patient during takeoff can prevent fluid accumulation in the patient's feet during acceleration.

Lateral forces are a possibility, though rare, during helicopter transport. Usually these lateral forces are of little consequence; many times the patient and crew are unaware of this type of movement. Lateral forces can also be experienced in ground transport while turning a corner. However, the driver of the vehicle should maneuver in such a manner that these forces do not harm the patient and crew.

PROLONGED IMMOBILIZATION

Evidence Based Practice Recommendation

According to the American Association of Neurological Surgeons, spinal immobilization in patients with penetrating trauma is not recommended because of increased mortality from delayed resuscitation.

https://www.cns.org/sites/default/files/guideline-chapter-pdf/Prehospital_Cervical_Spinal_Immobilization_After.6.pdf

Last Accessed: July 8, 2019

Level of Evidence: III (Strategy for patient management for which the clinical utility is uncertain.)

Often patient transfers involve long distances and, therefore, long transport times. The patient who is immobilized on a stretcher throughout a transport (either by land or by air) is subjected to a number of factors, including pressure sore development and venous stasis. Space limitations and the inability to change the patient's position exacerbate this problem. Patients at increased risk for complications include trauma patients, the elderly, and any patient with previously compromised circulatory status.

The patient at greatest risk is the patient with a spinal cord injury requiring transport on a backboard. It is important to remember that the time of immobilization is not only the length of the transport; ground transport times, unexpected delays, and transfer times should also be considered. As an example, a patient is injured in a motor vehicle accident at a remote site and is secured to a backboard to protect the cervical spine. The patient is then transported to the local hospital for stabilization and evaluation. The decision is made that the patient requires the expertise only available at a trauma center and arrangements for transport are initiated. During the evaluation of the patient, the x-rays are inconclusive and the patient is to remain on the backboard until a definitive diagnosis can be reached. Subsequently, the patient is taken by ground ambulance to the local airfield, flown to the airfield near the trauma center, and is again transferred by ground ambulance to the trauma center. The length of time from the scene of the accident to the trauma center may exceed 5 to 6 hours, although flight time was less than 1.5 hours.

Signs of poor perfusion are often difficult to assess during transport. Lighting is less than optimal; therefore, assessment of extremity color and capillary refill are hampered. The patient may complain of tingling or numbness in a compromised area; however, the patient with a decreased level of consciousness would be unable to report these sensory changes. Doppler monitor ultrasound can be utilized to assess for the presence of pulses in distal extremities. The absence of pulses requires further investigation of the cause and interventions to improve circulation.

The patient who is secured to a backboard runs the risk of pressure sore development in a number of locations. The most common pressure areas include the coccyx and sacral areas. Additionally, the scapulae are prone to compromised circulation. A patient in a hard cervical collar for spinal cord immobilization should be monitored for pressure sore development at the angles of the jaw and at the occiput of the skull.

Before departure, all splints, casts, and pressure areas should be padded. The patient on a backboard can have a small towel or pad placed under their back and coccyx area without risking a change in spinal cord alignment. During transport, proper positioning should be accomplished and, if possible, range of motion within the constraints of the vehicle can be performed. Constant vigilance of the extremities and areas of high risk before, during, and after the transport is required to prevent pressure sore development.

MOTION SICKNESS

Changes in inner ear equilibrium caused by unusual movements are the primary cause of motion sickness. However, other causes can include: hypoxia, excessive visual stimuli, stress, fear, unpleasant odors, heat, and poor diet. Gastric gas expansion that occurs on aircraft ascent can further potentiate the problem.

Nausea and vomiting are the two most common symptoms of motion sickness; other signs include chills and headache. In the transport environment, all persons are at risk of motion sickness, including the transport personnel. Those individuals who have a predisposition to motion sickness may prophylactically premedicate with transdermal patches. The problem that arises with the use of these patches is that, to be effective, they should be applied a half hour or more prior to departure; however, since these transports are generally not planned, this preventive measure may not be feasible.

To prevent or limit the effects of motion sickness, transport personnel should apply oxygen and ensure that the individual is in the supine position. Staring at a fixed object will help reduce the inner ear imbalance that precipitates the problem. Cooling the interior of the vehicle also will help reduce the symptoms. In severe cases, insertion of a nasogastric tube to suction will reduce gastric contents and vomiting.

Interestingly, transport personnel rarely, if ever, experience the symptoms of motion sickness while caring for a patient in transport. Most cases of crew motion sickness occur while on the way to pick up a patient. It appears that the concentration and work involved in caring for the patient helps overcome these complications.

NOISE

All transport vehicles are noisy. Engine noises create a constant loud hum; sirens in a ground ambulance are very loud and of a harsh intensity. Constant noise can create a stressful environment as well as increased irritability in all persons in the transport vehicle. Patients who are exposed to this constant input experience changes in their vital signs, including tachycardia and hypertension.

Reduction of environmental noise can be accomplished in a number of ways. Flight crews in helicopters utilize headsets to reduce noise input, as well as to allow for communication with other crew members. Headsets can also be used for the patient; however, it should be remembered that when noise reduction techniques are utilized on the patient they cannot hear normal conversation. This may prevent the patient from appropriately answering questions, as well as increase their anxiety when they assume that the crew is talking about them and they cannot figure out what is being said.

Cotton balls are the simplest form of noise reduction. However, they are easily forgotten when the patient arrives at the receiving hospital and communication may be difficult for this very simple reason. Another method employed to help the staff with the noise is the use of Doppler monitor devices to assist in obtaining vital signs or to assess for air movement through the trachea. A stethoscope may be rendered useless in obtaining vital signs in a very noisy environment, but it can assist in communicating with the patient. By placing the ear pieces into the patient's ears and speaking at the diaphragm, the patient may be able to better communicate with the crew.

The noises heard in ambulances, helicopters, and airplanes may be familiar to the transport crew; however, these same noises may produce fear in the patient. It is essential that the crew communicates with the patient, explaining all noises and lights. A preflight briefing will help alleviate some of these fears.

VIBRATION

Motion produces vibration. All transport vehicles are affected by vibration. However, this is most noticeable in a helicopter, especially during takeoff and landing. The biggest risk of vibration is the loosening of safety straps so that during a time of turbulence, equipment can come loose and pose a hazard to the safety of all. FAA regulations require that all equipment be secured for takeoff and landing in helicopters and airplanes; however, it is wise to keep all equipment secured at all times in the event of unexpected turbulence.

The patient should be secured onto the stretcher at all times. The safety straps used to secure the patient may be quite uncomfortable for them; during transport, these straps can be loosened slightly but should never be removed completely. The greatest risk comes to patients as they are being moved into and out of the transport vehicle.

Another problem with vibration is its effect upon equipment settings. Over time, constant vibration can cause a loosening of screws, so that equipment does not function properly. Mechanical ventilators are most prone to this complication; settings should be checked frequently during transport.

DECOMPRESSION SICKNESS

A rare and unexpected complication that can occur in a pressurized aircraft is the rapid loss of pressurization. This is an emergency situation in which the pilots of the aircraft will immediately put the aircraft into a steep descent to reduce the effects of atmospheric changes. When an aircraft loses its pressurization, the cabin pressure altitude immediately goes from its comfortable flying altitude (between 3,000–6,000 feet) to equilibrate with the altitude outside the aircraft (this can be up to 25,000–40,000 feet). The sudden decrease in cabin pressure produces all of the effects of altitude increase, including hypoxia, gas expansion, decreased temperature, and dehydration, with hypoxia causing the largest risk.

The immediate effects of a loss of pressurization depend upon the altitude of the aircraft at the time of the emergency; the higher the airplane, the greater the complications. The patient and crew could experience a number of problems including a ruptured eardrum, a drop in body temperature, and possibly wind burn, if the cause is due to a loss of a piece of the fuselage.

Decompression sickness is manifested by joint pain (the "bends"), paresthesias, central nervous system changes (e.g., headache, visual disturbances), and the "chokes" (a choking sensation). These symptoms are caused by the release of nitrogen bubbles into the blood stream.

Initially, when a loss of pressurization occurs, the crew is trained to put on their oxygen masks and protect themselves first. The pilots will don their oxygen masks and put the plane into an immediate descent. The crew should ensure that all equipment is secured and does not pose a hazard during this descent. The patient should have oxygen administered, or increased if he or she had previously been receiving oxygen. Symptoms of decompression sickness can be treated with oxygen therapy, or in severe cases, a decompression chamber with hyperbaric oxygen therapy.

Although rapid cabin decompressions rarely occur, transport personnel can now obtain training in handling of this type of emergency. The FAA and the U.S. Air Force have a joint training agreement to offer hypobaric chamber training to civilians at several U.S. Air Force Bases throughout the United States. This type of training allows the participants to experience the effects of decompression and the hypoxia associated with this untoward event, with the intent of being sufficiently trained in symptom recognition to protect themselves and their patients.

These ten stressors of transport are problems for all patients, some to a greater extent than others. Awareness of their probability and interventions to prevent their occurrence will limit the detrimental effects to the patient. Appropriate stabilization prior to transport will ensure that these effects will be minimized. Further stabilization measures will be discussed at length later in this course.

4. THE TRANSPORT PROCESS

TRANSPORT REGULATIONS

Local, state, and federal regulations all impact transport of patients, both in the air and on the ground. Healthcare providers who are facilitating a transport should be aware of how these regulations affect their choice of transport vehicle, as well as their legal responsibilities before, during, and at the end of the transport.

Ground ambulance regulations are developed at the state level by the Emergency Medical Services (EMS) office. These regulations can vary by state, but should meet the minimum standards as outlined in federal regulations. Most often these state regulations far exceed the minimum standards; however, they do vary significantly from state to state. Regulations are set for basic life support ambulances that are capable of providing advanced critical care measures. The equipment and training of the transport crew will vary depending on the services provided. Patient needs will dictate which type of transport vehicle is required for each transport.

Air ambulance operations are regulated by the FAA and should meet the requirements of a portion of the aviation regulation known as Part 135. These regulations stipulate the qualifications of the pilot-in-command and other flight crew members, maintenance requirements, and aviation management. Part 135 contains some of the most stringent of all the FAA regulations. Additionally, air transport crew members should be cognizant of the Federal Aviation Regulations (FARs) concerning in-flight safety and emergency procedures.

States may also regulate air ambulance operations within their state. To obtain licensure as an air ambulance, the transport program should meet certain minimum requirements. Although not required in all states, the legislative trend is to regulate the air ambulance operators to minimize the presence of those operating capricious services who believe they can make some extra money by transporting patients.

Accreditation is also available through the Commission on Accreditation of Medical Transport Systems (CAMTS). This is a voluntary review of an air transport program to ensure their compliance with patient care and safety standards. These standards are revised every two to three years. As of April 2019, there were 158 accredited medical air transport services in the United States [16].

Federal regulations also stipulate the requirements for the need to transport patients. These requirements were first introduced in 1985 as part of the Consolidated Omnibus Reconciliation Act (COBRA) and were subsequently amended in 1995 as a portion of the Medicare law, Emergency Medical Treatment and Labor Act (EMTALA). These laws state that all patients should have equal access to care and require the hospital to ensure that proper care is provided. If the hospital is incapable of providing care, arrangements should be made to transport the patient to a hospital with appropriate facilities. To ensure that the transport is performed in a safe and expeditious manner, the following conditions should be met [5]:

- The transferring hospital has provided medical care within its capacity to minimize risk to the patient's health.

- The receiving hospital has agreed to accept the patient and has the space and resources available for treatment.

- The transferring hospital sends available medical records with the patient.

- The transfer is affected through qualified personnel and transportation equipment.

It is the responsibility of all persons caring for patients to see that these regulations are followed.

INTERFACILITY TRANSFERS

Organization Before Transport

The transfer of patients requires preplanning in order to ensure that both the medical needs of the patient and federal requirements are met. Referring facilities should first assess their capabilities and recognize their limitations for patient care. When a patient is admitted who exceeds these capabilities, an interfacility transport should be effected. Assessment should include, but not be limited to, staffing, equipment capabilities, advanced diagnostic techniques, and the availability of in-house specialty care. Most patients' needs are well within these capabilities; however, it is important to recognize those patients whose needs exceed the available resources.

The receiving facility should also be assessed as to their capabilities for caring for the needs of the patient. As an example, trauma patients are best cared for in facilities that are designated trauma centers as verified by the American College of Surgeons Committee on Trauma. It is important that each area of care be individually assessed as to how they will meet the individual patient's needs.

Legal Considerations

Transferring a patient from one facility to another must meet the federal mandates of COBRA. Each institution should have protocols established for the referral and acceptance of transported patients. Physician-to-physician contact should be initiated prior to departure of the patient to the receiving facility. These physicians jointly share in the legal responsibility for the transport and should establish guidelines for patient care.

The risks and benefits of the transfer should be explained to the patient (or patient's legal representative), and a consent form should be signed to indicate that the patient has been informed. In the event that a patient is unable to give consent due to their medical condition, and no family or next-of-kin can be located, the patient can be transferred under the implied consent law. The law assumes that the patient would give consent if able. However, it is imperative that a concentrated effort be undertaken to locate family members before this type of consent is invoked.

Steps in Arranging Transport

After the determination has been made that a patient requires transport, there are a number of steps to be taken to ensure safe transport. The referring facility should choose the appropriate transport vehicle, ground, helicopter, or fixed wing. When a dedicated transport program is available, this decision is usually made by general agreement between the referring physician and the transport program. Air transport cannot be chosen indiscriminately; many third-party payers will only cover the cost of air transport when it is deemed medically necessary. The following is a list of steps that comprise an interfacility transfer:

1. Physician-to-physician communication

2. Selection of the appropriate mode of transport and personnel to accompany the patient

3. Signed consent for transfer, signed by the patient or legal representative

4. Stabilization of the patient to limit the stressors of transport

5. Completed documentation

6. Development of a plan of care to be provided in transport

7. Communication with all involved personnel and family

Transfer of Care

Transfer of care is not complete until the staff on the receiving unit has received a full report of the patient's status, and has received the appropriate documentation. The verbal report should include the patient's history, current illnesses or injuries, care received during transport, patient's responses to the transport, and any known plans for care at the receiving facility. Additionally, the receiving staff should be informed of the status of the patient's family, where they are, how to locate them, and if they are planning on arriving at the receiving facility.

The transport crew should turn care of the patient over to the receiving hospital staff immediately upon arrival. The transport crew members should not be delegated to deliver care to the patient once they have arrived at the receiving unit.

Before transfer is complete, a transport team member should notify the transferring facility of the safe arrival of the patient. Also, the patient's family should be notified that the patient is safe at the receiving hospital. Once all parties are notified, the transfer of care is complete.

5. STABILIZATION FOR TRANSPORT

AIRWAY AND BREATHING

Airway patency during transport is of primary importance. Potential airway compromise should be anticipated before transport so that proper interventions can be undertaken to ensure that the airway is protected. Performing airway maneuvers in a transport vehicle are, at a minimum, challenging and often are unsuccessful.

Evidence Based Practice Recommendation

According to the Eastern Association for the Surgery of Trauma, emergency tracheal intubation is indicated in trauma patients with airway obstruction, hypoventilation, persistent hypoxemia (arterial oxygen saturation ≤90%) despite supplemental oxygen, severe cognitive impairment (Glasgow Coma Scale score ≤8), severe hemorrhagic shock, or cardiac arrest.

https://www.east.org/education/practice-management-guidelines/endotracheal-intubation-following-trauma

Last Accessed: July 8, 2019

Strength of Recommendation: 1 (The recommendation is convincingly justifiable based on the available scientific information alone.)

Endotracheal intubation should be considered in any patient who has the potential to lose their airway due to aspiration, swelling, or edema. This may include patients with facial or neck burns, epiglottitis, facial fractures, or patients with an altered level of consciousness. Patients requiring mechanical ventilation and ventilatory support should be intubated in a controlled environment prior to departure. Examples of these patients include spinal cord injured patients, patients with chest wall injuries, or patients with other neurologic dysfunction.

Supplemental oxygen should be contemplated and is usually considered to be standard therapy during transport. All patients transported by air are at risk for hypoxia, as previously discussed, and should be considered as candidates for oxygen therapy. Figure 1 shows the predicted in-flight PO_2 for a patient, based upon his arterial blood gas results and the altitude at which the patient is to be transported (i.e., cabin altitude in a pressurized aircraft). You will note that a significant drop in the patient's oxygenation status occurs. As a general rule, it is estimated that inspired PO_2 declines approximately 5 mm/Hg per 1,000 feet ascended [6]. Unfortunately, no consensus formula exists to accurately predict PO_2 decline or how much the oxygen percentage should be increased to combat this drop in oxygenation [7,8]. Transport team members should rely on their astute assessment of the patient's color, capillary refill, and oxygen saturation results to determine how the patient is tolerating the transport.

Figure 1: PREDICTION OF IN-FLIGHT PO_2

Source: Compiled by Author

Chest tube placement may be accomplished prior to transport to decompress a pneumothorax. The patient who is being transported by air will have expansion of the pneumothorax if it is not treated prior to departure. In cases of an undetected pneumothorax, a flutter valve attached to a one-way valve can be placed to prevent further decompensation in the patient. A closed drainage system should be attached to the chest tube and a one-way valve should be in place to prevent complications should an accidental disconnect occur.

HEMODYNAMIC STABILIZATION

Maintenance of normal vital signs and circulating status is the goal of hemodynamic stabilization. Initially, control of bleeding should be instituted followed by volume resuscitation. Depending on the patient's status, two large-bore IVs should be initiated prior to transport; insertion during transport is very difficult.

Control of bleeding can be accomplished by a number of methods. Pressure dressings can be applied; however, the transport team should ensure that their supply of dressings is adequate in the event that the dressings become saturated and require replacement.

IV fluid resuscitation can be accomplished with one or two IV lines. Murphy's Law applies in the transport environment: if you have only one IV line it will become dislodged, if you have two lines they will both stay in. As noted, plastic IV bags are recommended; the problems of gas expansion are negated and, in cases of significant motion, a glass bottle could easily break.

Blood products can be administered in transport. Care should be taken to prevent the spoilage of blood; a cooler is usually adequate to keep blood cool prior to administration.

Monitoring urine output is one of the best indicators of the patient's fluid status. Insertion of an indwelling catheter will assist the transport crew with frequent assessment of volume status. Additionally, an indwelling catheter will relieve patient discomfort during long transport times.

Cardiac rhythm status should be frequently assessed using a transportable cardiac monitor. Continuous monitoring should commence prior to transport and continue throughout the transfer.

CENTRAL NERVOUS SYSTEM STABILIZATION

Deterioration of the patient's level of consciousness should be avoided during transport. Many of the stressors of transport induce rises in intracranial pressure. The transport crew should intervene to prevent this occurrence.

Prior to departure, an assessment of the patient's neurologic status should be completed. Utilizing the Glasgow Coma Scale, or other neurologic assessment scales, can assist in providing continuous information regarding patient condition. Medications, such as cranial volume reducers, can be initiated and continued in transport.

Any patient experiencing seizures should receive antiseizure medication. One of the most common causes of prolonged seizure activity is hypoxia; this condition worsens during air transport.

Patients with spinal cord trauma and neurologic deficits need special attention during transport to prevent further deterioration in neurologic status. Spinal precautions should include the use of a backboard and hard cervical collar. As discussed, pressure sore development is a common complication during long transports and care should be taken to pad all bony prominences. Administration of methylprednisolone or similar medication for spinal cord injury is a requisite and should be initiated and subsequently continued throughout transport.

MUSCULOSKELETAL STABILIZATION

Care in transport of the patient with musculoskeletal injury should include immobilization of fractures, wound care, and the proper administration of medications as ordered or required.

Appropriate splints should be applied prior to departure. Throughout the transport, frequent assessment of distal pulses should be performed. Air splints and pneumatic antishock garments should be monitored for the effects of gas expansion and changes in atmospheric temperature. Traction splints can be utilized; the use of traction weights is generally avoided as the weights can pose a hazard during unanticipated movement.

Extensive wound care is not possible in the transport environment. The transport crew members should act to preserve the integrity of a wound and prevent further contamination. A wound should be dressed and the dressing reinforced as necessary.

Patients requiring transfer for limb reimplantation require special care. The amputated part should be preserved by wrapping it in slightly moistened gauze and placing it into a plastic bag. The plastic bag should then be placed into a plastic container, such as an emesis basin or urine collection cup. This container should then be placed on ice in a cooler. The amputated part should not be allowed to freeze, as tissue destruction can occur, preventing the reimplantation.

Burn wounds causing a disruption of tissue integrity need special attention. The risk of contamination is great and interventions should be undertaken to reduce this risk. Further discussion of the transport of burned patients can be found later in this course.

EMOTIONAL STABILIZATION AND PSYCHOSOCIAL SUPPORT

After the physical needs of the patient who is about to be transported have been met, the emotional and psychologic aspects of transport should be addressed. If the patient and his or her family have fears or questions, intervention prior to the start of the transport can alleviate many of their worries.

It is vital that any counseling or other interventions take into consideration patients' cultural or linguistic barriers. When there is an obvious disconnect in the communication process between the practitioner and patient due to the patient's lack of proficiency in the English language, an interpreter is required. Interpreters are more than passive agents who translate and transmit information back and forth from party to party. When they are enlisted and treated as part of the interdisciplinary clinical team, they serve as cultural brokers, who ultimately enhance the clinical encounter. In any case in which information regarding transport options or expectations during a procedure are being provided, the use of an interpreter should be considered.

The patient who is transported is moved away from his family, friends, and familiar medical care providers. The need to be transported can be interpreted by the patient and family to mean that the patient is dying. While often this is true, patients are transported for a number of reasons with a variety of illnesses and injuries, and most do survive after reaching a healthcare facility that is capable of meeting their needs. The fear of dying is very real to the patient and family and should be addressed immediately after the decision to transport has been made. Healthcare providers cannot overestimate the capabilities of the receiving hospital, but an honest, forthright approach is appreciated by all involved.

The fear of death is only one of many feelings that the patient and family may be experiencing. If the patient is to be transported by air, they may have a fear of flying. The patient and family may be afraid that they will never see their loved ones again, and sometimes the resulting anger and resentment is directed at the referring hospital and healthcare personnel. The patient and/or family may feel that if the transferring hospital was better equipped, the need for the transport would be negated. It is the responsibility of the transporting crew to help the patient rebuild trust in their hospital; if the patient survives, they will most likely return to that home community for further healthcare needs.

The fears that the patient and family feel increase anxiety, which in turn can cause changes in the patient's status. The patient may become tachycardic, hypertensive, and may hyperventilate, all of which will compromise their illness or injury. Another complicating factor is pain; the patient whose pain is not well-controlled is incapable of handling the emotional impact that is placed upon them. It is important that the referring personnel, as well as the transport crew, provide adequate pain relief. The complications of narcotic delivery, such as pupillary constriction, may mask or confuse the signs of hypoxia, but uncontrolled pain is unacceptable and should be managed appropriately.

Family of the patient may develop what has been referred to as "Mecca syndrome." This is an overinflated idea of what can be done for the patient at the receiving hospital. The family wants to believe that the receiving hospital is flawless and can save or cure anyone. While the receiving hospital has greater capabilities than the transferring hospital in terms of diagnostic tools, equipment, and personnel, not all patients can be saved. Again, it is important to openly and honestly discuss the patient's condition and outcome with the patient as well as the family.

A family member may wish to accompany the patient during the transport. While this may initially appear to be a good idea, the transport crew should consider a number of factors prior to giving the go-ahead for an accompanying member. First and foremost, safety should be considered. A family member should have his or her own seat and be able to be secured with approved straps in the transport vehicle. Accompaniment is almost always impossible in a helicopter. Not only is there no room in the cabin for the family, the additional weight may put the helicopter over its operating weight and balance capabilities.

Another important consideration is patient status. A critically ill or injured patient may decompensate during transport and the presence of a family member may be detrimental. The family member will not be able to leave the transport vehicle, and will be present while possibly unsuccessful interventions are performed. Some family members try to be helpful while in reality they are in the way. Another problem is the family member who may develop motion sickness during the transport. The members of the transport team are responsible to the patient who is being transported; they may not be able to assist the family member because they are busy caring for the patient.

If a family member is to accompany a patient, they should receive a complete safety briefing prior to departure. The expectation of what they can and cannot do should be addressed. If time permits, they should be told to gather a few personal items to take with them, as their stay at the receiving facility may be a long one. Family members can be of benefit and included in the transport once these issues have been addressed. A parent is often very beneficial in comforting the pediatric patient. Additionally, once the patient has arrived at the receiving hospital, the parent is immediately available for decision-making and consent. While care is generally not withheld if a parent is not present, their presence is often appreciated by the receiving hospital staff.

The final decision as to whether a family member may accompany a transport is at the discretion of the transport crew. Often, individuals at the referring hospital tell family members that they can, only to be told at the last minute that they cannot accompany the patient. In an air transport, the pilot-in-command has the final decision-making authority. The decision is based upon weather and aircraft performance capabilities. In a ground transport, the transport crew member in charge is responsible for making this decision.

If a family member chooses not to accompany the patient, or is told that they are not allowed to be part of the transport, time should be made available for the family to say their good-byes to the patient. This may be the last time that the family sees the patient alive; the few seconds that it takes to share a last kiss or hug may make a tremendous difference in the family's ability to recover from the death. Prior to departure, the family should receive as much information as possible about the receiving hospital. Maps, telephone numbers, and plans for patient admission should all be included in this information. Additionally, the family should be informed of the estimated time of the transport and when they can expect to be notified of the safe arrival of their loved one at the receiving facility. It is imperative that the transport crew takes into consideration the weather, unexpected delays, and time zone changes. When providing the family with the estimated arrival time, it is always better to overestimate the time rather than to underestimate it. A telephone call that comes 10 minutes later than expected may seem like a lifetime to the waiting family. During this time, the family has imagined all types of horrible things that may have gone wrong in the transport, adding needless stress to their lives.

BASELINE DIAGNOSTIC STUDIES

Studies performed prior to transport depend upon a number of factors. Prehospital transports do not usually have the luxury of diagnostic tools. Patient stabilization is performed with consideration of the airway, breathing, and circulation (ABC), the mechanism of injury, and the history of the illness or injury. Interfacility transports have the time and more capabilities available to the patient.

The patient's illness or injury and current status will impact which studies are performed. The patient's airway should be examined and stabilized. Chest x-rays may be obtained to rule out any pulmonary complications that can compromise the patient during transport. Arterial blood gases will detect any abnormalities in oxygenation that the patient may be experiencing. Baseline blood studies, including hematocrit, will allow for determination of the patient's hematologic status. In emergent situations, only the basic studies that affect ABC should be performed, as time permits. Studies that should be performed if time permits include:

- Radiographs of cervical spine, chest, pelvis, and extremities that may be injured

- Laboratory tests, including hematocrit, hemoglobin content, arterial blood gas measurements, urinalysis, toxicology screens, blood alcohol measurements, and blood typing and crossmatching

- Electrocardiogram

Copies of all laboratory results, electrocardiogram, and radiographs should accompany the patient. These should be well labeled with the patient's name, time of the test, and notation of abnormal results. Additionally, samples of the patient's blood, peridialysis fluid, and spinal fluid should accompany the patient so that further testing may be instituted on these samples at the receiving facility. Any information that is not readily available at the time of the patient's departure patient should be telephoned or electronically transmitted to the receiving facility.

DOCUMENTATION

Documentation for transport includes information obtained during the prehospital period, the hospital phase of care, and during all phases of transport. Prehospital transport documentation should include, but not be limited to:

- Mechanism of injury or history

- Time of injury or onset of symptoms

- Time to arrival of EMS

- Care provided in the field

- Care provided en route

- Protocols or orders used during transport

Documentation and information that should accompany the patient who is being transported from one healthcare facility to another should include:

- Prehospital care record

- Emergency department record of care

- Medical history, if available

- Results of laboratory and diagnostic studies, as previously described

- Copies of radiographs (not just the radiologist's report)

- Transfer record

- Protocols or orders used in transport

- Signed transfer consent form

- Family information (name, address, telephone number for contact person)

- Name and telephone number of contact individual at referring facility

- Name of physician ordering transport and name of physician who has agreed to accept the patient at the receiving hospital

6. STABILIZATION OF SPECIFIC PATIENT POPULATIONS

The following discussion will examine eight patient populations who commonly require transport. Each disease process or injury will be reviewed and the ways in which the stressors of transport can affect each patient type will be discussed. Finally, each section will end with a case study. It is important to remember that during transport the patient cannot be fully evaluated and stabilized. Thus, the transport team's goal is to prevent further injury or compromise in the patient. Once the patient arrives at the receiving facility, an advanced level of care is instituted.

NEUROLOGICALLY COMPROMISED PATIENT

Evidence Based Practice Recommendation

The American Association of Neurological Surgeons recommends expeditious and careful transport of patients with acute cervical spine or spinal cord injuries from the site of injury by the most appropriate mode of transportation available to the nearest capable definitive care medical facility. Whenever possible, the transport of these patients to specialized acute spinal cord injury treatment centers is recommended.

https://www.cns.org/sites/default/files/guideline-chapter-pdf/Transportation_of_Patients_With_Acute_Traumatic.7.pdf

Last Accessed: July 8, 2019

Level of Evidence: III (Strategy for patient management for which the clinical utility is uncertain.)

The neurologically compromised patient is placed at great risk during transfer. Although there are many complications that can develop, the need to transfer the patient prevails, and the transport crew should intervene to limit these untoward problems.

Neurologically compromised patients are greatly impacted by the stressors of flight, including hypoxia, gas expansion, and decreased temperature. Hypoxia causes an increase in intracranial pressure and should be avoided by providing supplemental oxygen. A patient with an open skull fracture and air in the cranial cavity is at risk of herniation with gas expansion. Barotrauma within the ears, caused by gas expansion, will not be apparent in the unconscious patient. A decreased environmental temperature can cause shivering, which increases the patient's oxygen requirements up to 300% greater than normal. Obviously, in a previously compromised patient, this is to be avoided. Dehydration is generally not a problem, unless the patient has been placed under severe fluid restrictions in an effort to limit intracranial pressure. In this instance, the added effects of dehydration may be enough to cause cardiovascular collapse due to an inadequate circulating volume.

The effects of acceleration and deceleration forces on intracranial pressure have previously been presented. The transport crew should be cognizant of these forces and intervene to limit their effects. Patients with a decreased level of consciousness are not able to protect themselves by turning to avoid pressure sore development during long transports. Vomiting, associated with motion sickness, is generally not a problem; unconscious patients do not seem to experience the same responses as conscious patients. However, if the patient who is alert complains of nausea, measures should be taken to prevent the patient from vomiting, which increases intracranial pressure. Finally, noise and vibration increase anxiety and fear and have a detrimental effect on neurologic status.

Stabilization of the patient requires the use of supplemental oxygen, often at 100%. Intubation should be considered for all neurologically compromised patients, and oxygen saturations and end-tidal carbon dioxide levels should be monitored. Fluid status should be monitored to prevent dehydration. Guidelines for the management of cerebral trauma recommend maintaining the systolic blood pressure at 90 mm Hg [9]. Patients with suspected cervical spine injury should be transported on a hard backboard with spinal immobilization precautions. Positioning the patient with the head of the stretcher elevated, if tolerated, will reduce the effects of acceleration and deceleration forces. Prior to transport, pressure areas should be padded, and during transport, the patient's position should be changed within the confines of the transport vehicle. The use of cotton ear plugs can reduce extraneous noise; however, the effects of vibration are unavoidable. Neurotrauma patients receiving mannitol should have a Foley catheter placed for urine drainage and measurement of output volumes.

The use of paralytic agents in the transport environment has come under a great deal of scrutiny. The loss of respiratory drive accompanying neurologic compromise requires that the patient receive continuous ventilatory support. The beneficial effects of neuromuscular blocking agents on intracranial pressure often support their use. A patient who is comfortable and secure can be safely transported, while the agitated patient who is out of control can be a danger to himself as well as the other crew members. It is important to remember that paralysis can cause the patient to appear calm; however, their psychologic needs remain great. Patients who are chemically paralyzed should receive supplemental sedation and analgesia [10].

Neurologically Compromised Patient Case Study

Patient A, 18 years of age, sustains cervical spinal trauma when diving into a river. He has no demonstrated motor or sensory function below C3 and has no respiratory drive. He is rescued by a local ambulance crew and transported to the nearest facility, a small rural hospital with limited resources. The emergency room physician appropriately requests air transport of this patient to the Level 1 Trauma Center, located 350 miles away.

While awaiting transfer, Patient A is stabilized by the referring hospital staff. He had been placed on a backboard and in a hard cervical collar at the scene, and the staff ensure that he is well-secured to the board. His ventilations are continually being assisted through an endotracheal tube. Admission laboratory results are obtained, and all are within normal limits. Head-to-toe evaluation identifies no further injuries. Subsequently, a Foley catheter is placed. His medical records are copied, and a copy of his cervical spine radiograph is made.

The transport crew arrives and performs an assessment of the patient. The referring hospital personnel have done an exceptional job in stabilizing Patient A; the only interventions that the team performs are to restart an IV that appears somewhat unstable and to place small towels under his coccyx and shoulder blades to prevent pressure injury development. Although Patient A appeared to be quite healthy prior to this accident and is in no current distress, arterial blood gases are obtained to ensure that no respiratory complications exist. After the results are obtained, he is placed on the transport stretcher and secured for transport.

Just prior to leaving the hospital, a person comes through the door in tears, stating she is Patient A's fiancée. She runs to the stretcher and throws herself over the top of him. At this point, the patient starts to cry, and it appears that the emotional impact of this devastating injury is beginning to be felt. The fiancée wants to accompany the patient but is told that there is no room for her. The transport team allows Patient A and his fiancée a few moments together prior to departure.

During transport, a flight crew member notes that Patient A's body is quite cool. The cabin of the helicopter is air-conditioned, and the fan is blowing on the patient. Assuming that the spinal cord trauma disrupted his temperature regulating mechanisms, the team works to maintain an adequate body temperature.

Upon arrival at the trauma center, Patient A is evaluated in the emergency department. His core body temperature is 93 degrees and measures are undertaken to warm him. After further stabilization measures are performed, he is transferred to a spinal cord center, where he remains for four months, learning to use a portable ventilator and a wheelchair.

Discussion

The patient was well stabilized prior to the arrival of the transport team. The interventions the team performed could have been performed prior to their arrival if better communication had occurred. Advice on stabilization measures is always appreciated by the referring hospital staff and would have saved time at the referring hospital.

The psychologic aspects of Patient A's care were not fully evaluated prior to the arrival of the fiancée. Had the emergency department staff performed more in-depth evaluation of the impact of this injury, they would have learned of the fiancée's existence and could have called her earlier in his care. A tearful scene just prior to departure did not help the patient cope with the devastating injury.

In transport, the patient should have been kept warm. Allowing the patient's body temperature to drop to 93 degrees was an oversight on the part of the transport crew. In all transports, the crew should evaluate the patient for complications of the illness or injury sustained, not just how the patient will tolerate the stressors of transport.

RESPIRATORY PATIENT

Because many of the stressors of flight directly impact the respiratory system, the patient with respiratory compromise can be difficult to care for during transport. The predisposition to oxygen desaturation and respiratory failure is high.

Hypoxia is an enormous problem for the respiratory patient. The illness or injury may have caused the patient to experience the four types of hypoxia: hypoxic, histologic, anemic, and stagnant. Coupled with anxiety, fear, and pain that the patient may be experiencing, the patient is at risk for further respiratory insufficiency. Hypoxic hypoxia that occurs during air transport reduces the diffusion gradient for the oxygen molecules. The patient with fluid in his or her alveoli has a greater distance for diffusion, and the patient becomes more hypoxic at altitude. Increasing the oxygen percentage that the patient is receiving will increase the oxygen diffusion gradient, thereby minimizing the effects of atmospheric changes.

Gas expansion within the pleural and abdominal cavities compromises ventilatory effort. Undetected or untreated, pneumothoraces will expand at altitude, leading to worsening respiratory status. Gas expansion in the stomach causes pressure on the diaphragm, limiting respiratory excursion effort and subsequent ventilatory limitations.

Pulmonary secretions increase in tenacity in a low humidity environment. If the patient is prone to developing plugs in the respiratory tree, transport at altitude will enhance plug formation. Patients who hyperventilate lose additional insensible water through their respiratory tree, increasing the risk for volume depletion. This is an additional problem for the patient with a decreased body temperature whose compensatory response to cold stress is to hyperventilate. A decrease in body temperature of 2 degrees centigrade causes oxygen consumption to double. Therefore, the problems of decreased temperature and hypoxia potentiate one another.

If the patient's volume status is compromised, acceleration and deceleration forces can reduce venous return to the heart. This leads to a subsequent decrease in pulmonary circulation, further hampering oxygen diffusion. Additionally, deceleration forces can precipitate pulmonary venous pooling and pulmonary stasis.

Patients transported on stretchers should be secured with safety straps, usually placed over the chest. If these straps are too tight, full lung expansion is prevented. This immobilization also promotes atelectasis and pulmonary stasis.

Motion sickness can be avoided by the insertion of a nasogastric tube. Vomiting, if it occurs, can lead to shortness of breath and respiratory compromise. Both noise and vibration affect the respiratory patient; increased anxiety can increase respiratory rate, leading to further hypoxia and insensible water losses. Noise also limits the ability to fully auscultate breath sounds. An important part of assessment is lost in the transport environment, but efforts at assessment can include monitoring for chest expansion and placing the patient on a pulse oximeter to monitor for signs of oxygen desaturation.

In long transports, respiratory patients may require mechanical ventilator support. During air transport, a ventilator should be continually checked. Tidal volumes can be affected by gas expansion; commonly, the tidal volumes delivered will increase incrementally. For most patients, this increase in tidal volume is tolerable. However, there are some patients who cannot tolerate these minor changes in volume and they subsequently develop pneumothoraces. Additionally, ventilators require up to 15 liters/minute of air flow to function properly. This high flow rate rapidly depletes oxygen supplies, which, if not closely monitored, can be life-threatening to the patient.

Sickle cell patients are at increased risk during air transport as hypoxia predisposes the patient to a crisis. This patient's oxygenation status should be maximized to prevent this occurrence.

Stabilization interventions require that the patient with respiratory compromise be administered supplemental oxygen with an increased oxygen percentage. Restoring optimum circulating blood volume with blood products, if needed, will improve the oxygen-carrying capacity of the blood. The patient should be positioned for best oxygenation and gas exchange. If tolerated and feasible, the head of the stretcher should be elevated. This will allow for improved lung expansion and prevent pulmonary stasis. A pneumothorax should be treated with either a flutter valve, or preferably, a chest tube attached to a one-way (Heimlich) valve. Humidification of the delivered oxygen will reduce the incidence of plug formation; sterile saline can be instilled through the endotracheal tube prior to suctioning. Methods should be employed to limit heat loss in patients, including warming the oxygen, covering the patient with an adequate supply of linen, and maintaining an ambient temperature that is comfortable for the patient instead of the crew.

Respiratory Case Study

Patient B is 5 years of age and is found at the bottom of her grandmother's pool on a cold winter day. She is pulled from the water by the paramedics, and resuscitation efforts are initiated. She is found to have an agonal rhythm and intermittent spontaneous respirations. Cardiopulmonary resuscitation (CPR) is continued, and she is transported to the local children's hospital, approximately 55 minutes away by ambulance.

Prior to transport, the paramedics intubate the patient with a 5.0 endotracheal tube and start one IV line in her antecubital fossa. She is continually hand ventilated with 100% oxygen at an approximate rate of 30 breaths per minute. Her wet clothing is removed, and she is covered with a rescue blanket.

During transport, Patient B develops a bradycardic rhythm with occasional ventricular ectopy. She is given a weight-appropriate dose of atropine, and her heart rate remains between 90 and 100 beats per minute. Standing orders prescribe the administration of sodium bicarbonate, and she receives this dose 30 minutes before arrival at the children's hospital.

Upon arrival, Patient B's vital signs are: pulse 90 beats per minute; blood pressure 86/52 mm Hg; assisted ventilations at 30 per minute; and temperature of 91 degrees. Immediate interventions include rechecking her ABCs and obtaining a chest x-ray to confirm endotracheal tube placement. A set of arterial blood gases are obtained, and the results are: PO_2 65; partial pressure of carbon dioxide (PCO_2) 53; pH 7.23. Efforts are initiated to warm her, and after two hours, her body temperature is 96 degrees.

She is admitted to the pediatric intensive care unit (ICU), where she can be closely monitored. During the first 24 hours, an intracranial pressure monitor is inserted and signs of increased intracranial pressure are evident. The diagnosis of severe anoxic brain injury is made, and Patient B remains in a vegetative state.

Discussion

This case presents some of the dilemmas that are present in the prehospital care environment. One may ask why the paramedics chose to drive this child by ambulance rather than request helicopter transfer, the answer being quite simple; the helicopter was out-of-service at the time and the crew had no other options available to them.

In the prehospital environment, preparation for transport includes stabilization of the ABCs. Few diagnostic measures can be undertaken; the crew must rely on its initial assessment findings. Patient B was intubated, was ventilated with 100% oxygen, and had an IV line started, thus managing the ABCs. Her wet clothing was removed, but she was quite hypothermic upon arrival at the children's hospital. It would have helped to wrap the patient's head with a towel in transport and then replace this towel after it was water saturated to conserve body heat, as every body surface is equally susceptible to heat loss.

The patient also was predisposed to the problems previously discussed in the neurologically compromised patient. Her anoxic injury caused an increased intracranial pressure and the noise and vibrations experienced during the ambulance ride may have worsened this condition. Another measure that was not undertaken, but that should have at least been considered, is the placement of a nasogastric tube. The moving vehicle could have predisposed this child to vomiting and the risk of aspiration. If circumstances were different, other interventions may have been undertaken, including placement of a Foley catheter.

CARDIOVASCULAR PATIENT

Cardiovascular patients requiring transport generally fall into two categories: those who are experiencing acute myocardial infarction or acute coronary syndrome, or patients with rhythm disturbances. The stressors of transport are debilitating to these patients if interventions are not performed to minimize the harmful effects.

Hypoxia is a significant complication to these patients due to a compromised myocardium. The compensatory response to hypoxia is tachycardia, which will lead to an increased cardiac oxygen demand. This demand is further enhanced by fear, anxiety, and pain, and supplemental oxygen is a requirement for these patients. Stagnant hypoxia caused by a damaged myocardium further intensifies the damage sustained. Continual real-time cardiac and respiratory monitoring to detect further hypoxic complications should be employed at all times throughout the course of care.

The altitude-induced problems of gas expansion, decreased temperature, and dehydration may or may not impact the patient. Gas expansion within the stomach can lead to vomiting, and this can limit blood flow back to the heart. The insertion of a nasogastric tube would solve this problem. However, the insertion of the tube may be more stressful and harmful to the patient than the risk of vomiting. Patients in severe cardiogenic shock with poor peripheral perfusion may exhibit cool and clammy extremities; core temperature would worsen in this state. During transport, most cardiovascular patients are placed on fluid restrictions. If the patient's condition is severe, the dehydrating environment that occurs in air transport could restrict their fluid status to the point of experiencing cardiovascular collapse.

The effects of acceleration and deceleration forces are prominent in this patient population. Compromised circulation is worsened in the presence of these forces. It is critical that these patients be positioned for maximum cardiac return and function. Cardiac congestion is common with both acceleration and deceleration forces and should be avoided if at all possible.

Patients with a lengthy cardiac history are predisposed to circulatory complications, both centrally and peripherally. The peripheral venous congestion that occurs enhances the risk of pressure sore development during long transports. The application of antiembolism stockings or other types of devices can limit thrombophlebitis formation in the lower extremities.

Cardiac patients require continuous monitoring and cardiac support. The transport team should utilize a cardiac monitor that is not affected by radio transmissions. Pacemakers should be functional in all environments and shielded from emissions. Defibrillators should be used with caution so that damage does not occur to the vehicle or other medical equipment.

In severe cases of cardiac failure, a patient may require an intra-aortic balloon pump. There are transportable pumps now available that have been used with great success. The most important parameter to assess when using a balloon in a patient during air transport is the balloon itself, as the balloon can be affected by gas expansion. Another device utilized in transport to stabilize the critically ill cardiovascular patient is the biventricular assist device, which requires extensive pretransport training and expertise on behalf of the transport crew.

Patients requiring continuous infusions of cardiac support medications are often transported. It is imperative that the crew be aware of this requirement prior to the transport to ensure that an adequate supply of medication is available. This supply should take into account unexpected delays. Transportable infusion devices are useful in delivering the prescribed amount of medication required. One of the classes of medication for which these concepts are critical are thrombolytic agents. Should the team be delayed, additional medication should be available, or, if the supply of the primary medication is exhausted, alternative drugs should be administered according to protocol.

Stabilization of the cardiac patient requires efforts to maximize cardiac function without compromising cardiac reserve. These patients have a fine line under which they can function and all interventions should be instituted to stabilize the patient prior to transport.

Cardiovascular Case Study

Patient C is a man, 62 years of age, who is complaining of chest pain upon his arrival at the local hospital. Evaluation of his complaints, laboratory studies, and chest pain demonstrate a massive anterolateral myocardial infarction. Thirty minutes after arrival in the emergency department, the patient sustains a cardiac arrest secondary to ventricular fibrillation. He is successfully resuscitated utilizing advanced life support measures. After the cardiac arrest, he remains quite unstable, having multiple runs of ventricular tachycardia despite multiple antiarrhythmics. The emergency physician consults with the cardiac care center at the referral hospital, and the patient is accepted into their care. Arrangements for air transport are made and Patient C is stabilized according to the instructions of the consulting cardiologist.

While awaiting the arrival of the air transport team, the referring personnel obtain a set of arterial blood gases for measurement. The patient's PO_2 remains at 72 despite increasing the oxygen percentage delivered. A second IV line is started per instructions. It is decided not to insert a nasogastric tube, as it has been more than six hours since Patient C last ate and he states he has never experienced motion sickness.

Upon arrival of the transport team, the patient is moved to the transport stretcher. While moving the patient, increased ventricular ectopy is noted. The dosage of antiarrhythmic medication is increased and the oxygen face mask is replaced with a non-rebreather mask, which is capable of a higher oxygen concentration delivery. The patient is transferred to the waiting helicopter, and the team takes off.

During the initial moments of the transport, Patient C is very alert and interested in his surroundings, asking many questions about the helicopter. Within fifteen minutes, the patient becomes quiet and appears to be dozing. However, at the same time, the crew notice another increase in ventricular ectopy. While another IV drip is being mixed, the patient sustains a cardiac arrest in the helicopter. CPR is initiated, and attempts at intubation are made. Finally, after the fourth attempt, an endotracheal tube is successfully placed, and the patient is ventilated with 100% oxygen. The crew suspects that the cause of the arrest is a hypoxic myocardium secondary to the hypoxia associated with altitude. After 15 minutes of CPR and resuscitation efforts, Patient C again regains a cardiac rhythm and is stabilized. His condition remains critical; he remains comatose after cardiac arrest in the helicopter and is admitted to the cardiac care center in a severe cardiogenic shock. He has an intra-aortic balloon inserted and is supported on the pump for two weeks. After that time, without improvement in his condition, his family chooses to discontinue the balloon pump, and the patient dies shortly thereafter.

Discussion

Patient C's critical condition was not fully recognized by the individuals caring for him. He was alert and awake and this may have caused the healthcare providers to be complacent in their evaluation of him. He had no previous cardiac history and he was not considered to be a high risk individual. The ectopy that he sustained in the emergency department is common after a large myocardial infarction and should have alerted the physicians and nurses to his tenuous condition.

The stabilization measures undertaken by the staff were appropriate and thorough. With a PO_2 of 72 and a cardiac arrest, Patient C was a candidate for endotracheal intubation. The flight crew should have been aware of the risks inherent in transporting this patient, and he should have been intubated prior to departure. Multiple intubation attempts in the helicopter are not uncommon; it is a difficult environment, with poor lighting and poor patient access.

This patient's outcome may or may not have been affected by the omissions of the referring personnel and the flight team members. However, they should have better assessed the severity of the patient's condition and intervened as necessary.

BURN PATIENT

Evidence Based Practice Recommendation

Because burn patients who have concomitant trauma have greater risk for morbidity and mortality, the National Expert Panel on Field Triage recommends transfer to a burn center. If the nonburn injury presents a greater immediate risk, the patient should be stabilized in a trauma center and then transferred to a burn center.

https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6101a1.htm.

Last Accessed: July 8, 2019

Level of Evidence: Expert Opinion/Consensus Statement

Burn patients require transport to a burn center whenever they have large, deep burns or burns that involve the face, hands, feet, or joints. The American College of Surgeons Committee on Trauma published classifications of patients requiring treatment at a burn center, including [11]:

- Partial thickness burns over more than 10% of the total body surface area (TBSA)

- Burns involving the face, hands, feet, genitalia, perineum, or major joints

- Third-degree burns in any age group

- Electrical burns, including lightning injuries

- Chemical burns

- Inhalation injuries

- Burn injury in patients with significant pre-existing medical disorders that could complicate management, prolong recovery, or affect mortality

- Patients with burns and concomitant trauma when the burn injury poses the highest risk of morbidity or mortality

- Burn injury in pediatric patients (transfer to burn center for the care of children)

- Burn injury in patients who will require special social, emotional, and/or long-term rehabilitative intervention(s)

Burn patients are transferred daily from the scene of a fire (or injury) to the local medical care facility. Prehospital care of the burned individual should include:

- Removing constrictive clothing and jewelry

- Covering the patient with a clean sheet or blanket

- Maintaining the patient in a position of comfort, usually flat

- Avoiding application of ice or ointments to the wound

- Flushing chemical injuries continuously

- Initiating IV fluid resuscitation in major burn victims to maintain blood pressure and heart rate

Airway management is critical in the early moments following a burn injury. Airway edema develops rapidly and early intubation is recommended in patients with signs of impending airway compromise. If intubation is delayed, airway swelling will prevent placement of an appropriate size endotracheal tube and a smaller diameter tube must then be utilized. It is difficult to ventilate a patient through a smaller size tube, thus hindering ventilatory assistance. Patients should be administered 100% oxygen. Oxygen will break the chemical bond between carbon monoxide molecules and hemoglobin, thus improving the patient's oxygenation status.

Patient stabilization also includes circulatory support with either oral or IV fluids. Utilizing IV fluids in burns of greater than 20% TBSA is usually recommended because large volumes of oral fluids are neither tolerated nor absorbed. The 20% TBSA recommendation is simply a guideline. Interventions should be based on each patient's individual needs. Starting IV fluids in the prehospital care environment offers two advantages. First, IV line placement may be more easily obtained as peripheral swelling has not had sufficient time to develop. Secondly, the formulas for fluid resuscitation utilize the time of the burn injury as the starting point for resuscitation; delay in placing the line will make resuscitation efforts more difficult.

Lactated Ringer's solution remains the fluid of choice for fluid resuscitation, although other solutions are utilized in some parts of the country [12]. Fluid needs are based on the patient's weight in kilograms and the percentage of body surface area injured.

The fluid resuscitation formula most commonly utilized for adults with severe burns is the Parkland formula [12]:

4 cc x weight in kilograms x % BSA injured

Half of this calculated amount should be delivered in the first eight hours after the injury, the remainder over the subsequent sixteen hours. As an example, an 80 kilogram male with a 40% TBSA burn would require 12,800 cc during the first 24 hours (4 x 80 x 40). To receive half of this volume in the first eight hours, the patient should receive fluids at a rate of 800 cc/hr. During the second sixteen hours, the fluids would be infused at 400 cc/hr. It is important to calculate this volume correctly and ensure that adequate fluids are available throughout the transport of the patient. Monitoring blood pressure and weight-based urine output should ultimately guide fluid volume administration.

After evaluation of the burn injury, the decision to transport the injured patient to a burn center should be made. Based upon the criteria listed above, referral to the physicians at the facility should be initiated. Further stabilization of the patient, prior to transport to a burn center, should take into consideration the stressors of transport. Interventions should be instituted to limit these problems.

Air transport of burn patients is common as burn centers are often located many miles from the scene of the injury. Inhalation burns and burns of the face, head, and neck all predispose the patient to significant hypoxia. The hypoxia experienced in air transport potentiates this problem significantly. It is crucial that the patient have a secure airway. If the patient is intubated, the tube should be well secured. Burns of the face will weep fluid and render standard adhesive tape ineffective, leading to easy dislodgment of the endotracheal tube. Trach tape is often used to tie the tube in place, preventing this devastating complication.

The patient's head should be elevated as much as possible to limit edema formation. Supplemental oxygen should be continued with 100% oxygen, and cooling and humidifying the oxygen will help prevent airway edema formation. A patient who does not require intubation should be monitored continuously for ventilatory compromise, which may be developing secondary to smoke inhalation. This patient should always have an intubation set readily available at the bedside.

Gas expansion in the abdominal cavity is complicated by the development of an ileus. Ileus formation is quite common following a burn injury and will prevent the passage of gastric contents. A nasogastric tube and suctioning will help limit these effects, reducing the risk of vomiting and aspiration.

Hypovolemia is one of the most common problems occurring after a burn injury. Patients with partial thickness burns are at greatest risk of significant fluid loss. This loss of fluid, coupled with the dehydration that occurs in air transport, further compromises the patient's volume status. Evaporative losses are enhanced in the dry cabin environment, further increasing the patient's need for hydration. Prior to transport, a patient should be stabilized with IV fluids and all wounds should be covered with absorbent dressings. The transport team should be aware of the patient's fluid requirements. When determining how much fluid to take in transport, the patient's needs are calculated and that amount is increased again by half. A Foley catheter should be placed to monitor urine output, as this is the best indicator of the patient's response to fluid resuscitation efforts [13].

One of the biggest problems for the burn patient that occurs in all modes of transport is a subnormal temperature. With the loss of skin from the burn injury, the patient has lost his or her temperature regulating mechanism. In the best of situations, most burn patients become hypothermic, and the transport environment is not considered to be optimal for these patients. It is important that efforts be undertaken to keep the patient warm. This includes covering the wounds with dry dressings. When these dressings become saturated they should be reinforced with additional dry dressings. The patient can be wrapped in a rescue blanket; however, there are reported cases of patients becoming overheated in these blankets when wrapped too tightly. Additional blankets and linen will also help keep the patient warm. Covering the head with a hat is beneficial, especially in children and the elderly.

The hypovolemic shock that develops after a severe burn predisposes the patient to complications of acceleration and deceleration forces. The patient should be adequately fluid resuscitated to assist in combating these forces. Positioning the patient with the feet elevated will prevent blood from pooling in this region.

Immobilization of the burned individual enhances edema formation and can cause the extent and depth of the burn to increase. Lying on burn wounds is not only uncomfortable for the patient but limits circulation to the injured area. All wounds should be dressed prior to transport; these dressings need to be checked periodically to ensure that they have not become too tight from increased edema formation. Elevation of dependent limbs will limit edema formation, and it is important to check that all rings, necklaces, and other constricting devices were removed in the prehospital environment.

As noted, ileus formation promotes nausea and vomiting; however, a nasogastric tube to suction will limit these effects. The noise and vibration from the transport may increase the patient's stress level and efforts should be made to limit as much environmental input as possible.

Additional considerations in the transport of burn patients include pain control and the prevention of infection. Burn patients have a significant amount of pain, coupled with the devastating psychosocial and emotional impact of being burned. Small frequent intravenous doses of narcotics are useful in controlling some of the pain the patient is experiencing. Burn patients have very high metabolic rates that increase the metabolism of the narcotics, causing their length of action to decrease dramatically. Administering doses every 15 to 20 minutes is not uncommon. Therefore, it is important to have an adequate supply of narcotics available for the estimated length of transport. Most transport programs carry a limited supply of narcotics, so securing additional narcotics from the transferring hospital may be necessary. Additionally, the patient may be administered sedative agents to decrease awareness of the environmental input.

The transport environment is not a clean, sterile environment. Meticulous care should be provided to limit contamination of the patient's wounds. Applying topical antibiotics has the advantage of limiting the risk of wound contamination; however, these topical agents should be removed upon arrival at the burn center, delaying other interventions. In determining if topical agents should be used, each individual case should be considered and recommendations from the burn center should be utilized.

Transporting the burn patient requires a significant amount of preplanning and stabilization, as well as a great deal of work during transport. With proper stabilization and interventions, most burn patients tolerate the transport without complications.

Burn Patient Case Study

Patient D is a man, 23 years of age, who was burned when a propane heater exploded while he was sleeping in his camper. He was able to escape from the camper prior to the entire truck exploding into flames. However, he sustained more than 60% partial- and full-thickness burns, mostly of the lower torso, back, and legs. He is treated at the scene by a volunteer ambulance crew that is only trained in basic life support measures. They apply an oxygen face mask, cover the patient with blankets, and transport him to the nearest facility 90 minutes away. The facility is a rural hospital, staffed by nurse practitioners and physician assistants, with a physician on-call 45 minutes away.

Upon arrival at this facility, placement of an IV line is attempted. After 45 minutes of unsuccessful attempts, the physician arrives and places a brachial cutdown. Lactated Ringer's solution is started, and initially the fluid was run wide open. Evaluation of Patient D's injuries includes calculating body surface area involvement, which is determined to be approximately 60%. He weighs 70 kilograms, and according to the fluid resuscitation formulas, his fluid requirements for the first 24 hours are 16,800 cc. Based on this calculation, the calculated fluid infusion rate is 1,050 cc/hour for the first eight hours. However, it is important to remember that this formula is based upon starting the IV fluids at the time of injury. By the time the line is placed, more than 2.5 hours have passed. This means that the patient is more than 2 liters behind (if utilizing the Parkland formula). Depending on the patient's condition, fluids can be increased so that the calculated amount is given in the first eight hours, or fluids can be administered according to the calculated formula and the patient monitored for response to these fluids. Patient D is an active, healthy young male without pre-existing medical diseases, and the decision is made to increase the fluid infusion rate to catch him up to these calculated needs. He tolerates this without problems, maintaining a normal blood pressure and an adequate urine output.

In assessing this patient, it is noted that he has singed hair on his head and mustache. No burns are noted on his head, and his airway appears clear. The oxygen delivery system is switched to a non-rebreather mask, capable of delivering approximately 95% to 100% oxygen. The decision to intubate is delayed at this time. Other interventions include cleaning and dressing his wounds and placement of a Foley catheter. He is administered 100 mg of intramuscular meperidine for pain. Arrangements for air transport to the burn center are initiated.

Upon arrival of the helicopter, the transport crew performs an assessment of Patient D. His airway remains clear without evidence of swelling, and the team chooses not to intubate him. The Lactated Ringer's solution had continued wide open, and he has received 5 liters of fluid up to this point. The team slows the infusion to a rate of 900 cc/hour with the knowledge that the patient's urine output had been greater than 50 cc/hour during the last hour.

The patient's dressings are reinforced with dry dressings, and the extremities are elevated to decrease edema formation. Throughout their assessment, the patient continually complains of pain. He is given 10 mg of morphine sulfate IV, with some relief of pain. The meperidine that he received intramuscularly was most likely sitting at the site of injection as his circulation was poor and was, therefore, not helping to relieve his pain.

The patient is transferred to the transport stretcher, and efforts are made to keep him as comfortable as possible. Due to the location of his burns, it is impossible to keep him from lying on his wounds; the team works to make subtle position changes as often as possible. The helicopter trip to pick up the patient is turbulent. The team wants to reduce the risk of motion sickness and vomiting on the return trip, so prior to departure, they place a nasogastric tube.

In transport, Patient D continues to complain of pain and is given frequent small doses of IV morphine sulfate. Upon arrival at the burn center, it is noted that he had received more than 50 mg of IV morphine sulfate, without compromise to his ventilatory status. In fact, the patient continues to complain of pain, although he does note some relief of its severity.

The patient remains stable during the transport. Upon arrival, his vital signs are stable, urine output remains more than 50 cc/hour, and his core body temperature is 96 degrees. He is admitted to the burn center, and the next morning has grafting over 35% of his wounds. After a lengthy stay at the facility, he is released with appointments for rehabilitation.

MULTIPLE TRAUMA PATIENT

The multiple trauma patient has many problems that impact most body systems, thereby increasing the chance that the stressors of transport will be harmful to the patient. Transporting the patient by air is often required due to the large distances between trauma centers. This mode of transport increases the risk of compromise, and interventions need to be performed to reduce these risks.

Hypoxia is common in any patient sustaining chest trauma. Pneumothorax will compromise ventilatory effort and the patient should be decompressed with either a flutter valve or chest tube. Patients with chest wall injuries will have a decreased chest excursion effort and will need to be positioned for maximal ventilatory function. Dyspnea may be a sign of increasing hypoxia, but the transport team should also rule out the possibility of a pulmonary embolus as the cause of the hypoxia.

It is important to remember that gas expansion can compromise physiologic functioning of the patient, but it can also impact equipment such as air splints. During transport, these pieces of equipment should be continually checked for an increase in pressure on the involved extremity, which may harm neurovascular function. Wounds (e.g., bowel rupture) that lead to the formation of free air within the body cavities should be decompressed as the free air will expand causing further damage. Gas expansion within the stomach will predispose the patient to vomiting associated with motion sickness.

Hypovolemia, secondary to blood loss, is a common complication of trauma. Additional fluid loss in the form of evaporative losses in a pressurized aircraft will further jeopardize circulatory function. Patients in hypovolemic shock are also predisposed to the complications of acceleration and deceleration forces. Ensuring adequate fluid replacement prior to departure will prevent this complication.

Patients with traumatic injury to the central nervous system may have lost their thermoregulatory capabilities, enhancing the risk of hypothermia in transport. IV fluids should be warmed prior to administration and patients should be adequately protected from evaporative and radiated heat losses. Removing any wet or saturated clothing or linen should be done prior to departure.

Trauma to the musculoskeletal system requires the placement of splints and other stabilizing devices. Casts should be bivalved to prevent edematous compromise and traction devices should be monitored for causing circulatory impairment. As mentioned, traction weights should not be utilized in the transport environment, as these become a hazard during turbulence and motion.

Most trauma patients will have a nasogastric tube inserted during initial resuscitation. This tube should remain in place for transport to limit the risk of vomiting with motion. Any trauma patient who has had their jaw wired shut should be transported with a pair of wire cutters at the head of the stretcher.

With a multitude of equipment, lines, and interventions, multiple trauma patients require a tremendous amount of care during transport. Administering fluid, blood, and medications is time-consuming. When coupled with frequent vital sign checks and checks of equipment function, the transport crew is constantly working to stabilize the patient. To have a family member accompany the patient in this situation can be a benefit and a detriment. On the positive side, the family member can assist with the emotional needs of the patient, while on the negative side, they may be in the way of the crew, preventing their attention from being focused completely on the patient.

Transport crews will often say that the most challenging and the most rewarding transport is the trauma patient. The time in transport goes quickly and a number of interventions are performed. Being involved in a transport that can mean the difference between life and death of a patient is a very exhilarating experience and one on which many transport crew members thrive.

Multiple Trauma Case Study

Patient E is a man, 33 years of age, working in a logging camp during the summer months. He is a well-conditioned, active male with a love of the outdoors. While at work one day, a log falls from the logging truck, crushing him beneath the weight. An emergency medical technician (EMT) who works at the logging camp rushes to the scene and directs the care of the patient while the log is being lifted off him.

Patient E sustains significant trauma to his chest, abdomen, and lower extremities. He is awake, talking, and in a tremendous amount of pain. The EMT is only trained in basic life support measures; he applies an oxygen mask to Patient E and directs an associate to call for helicopter transport to the local trauma center. While awaiting the arrival of the helicopter, the EMT places the patient in air splints to stabilize his suspected fractures.

When the helicopter crew arrives, the team immediately chooses to intubate the patient. Although he is maintaining his airway at present, he continues to lose blood and his condition is becoming more serious. Two large bore IV lines are started, one on each upper extremity. Lactated Ringer's solution is infused wide open until the patient has received two liters of fluid. The air splints on his lower extremities limit the ability of the team to examine the injuries to Patient E's lower extremities. By the EMT's report, Patient E has sustained multiple bruises to the lower abdomen, a displaced pelvis, and an obvious fracture to the left femur. The crew is able to palpate distal pulses on the right and left feet, the left pulse being slightly weaker than the right. As the transport is relatively short (25 minutes), the patient is loaded into the helicopter.

During transport, the patient's neurologic status appears to decompensate. The patient is no longer awake and responding to the transport crew. At this point the crew increases the oxygen percentage to 100% and obtains another set of vital signs. The patient's systolic blood pressure drops by 20 points, and fluids are again run at a wide open rate. A check of his peripheral pulses shows a diminished pulse of the right foot, with no change noted in the pulse on the left foot.

The patient is attached to a pulse oximeter for the transport and at this point it is noted that his oxygen saturation has dropped from 94% to 80%. Placement of the endotracheal tube is checked and the oxygen system is evaluated for proper functioning. When all components are evaluated and found to be functioning properly, it is assumed that the patient has developed a complication secondary to the chest trauma. The most obvious complication would be the development of a pneumothorax, and a flutter valve is placed. Immediately after placement, the patient's oxygen saturation increases to 88% and subsequently rises to 90%.

Upon arrival at the trauma center, the trauma team evaluates the patient and performs a head-to-toe assessment. A chest x-ray is obtained and confirms the development of a pneumothorax, as suspected by the transport team. During the assessment of the patient, it is noted that he has a cold, pulseless right foot. The mechanisms of injury and patient history are again evaluated in an effort to determine the cause of this complication. The femur fracture noted by the EMT at the logging camp is on the left side; it is suspected that an undiagnosed fracture has also occurred on the right side.

As the air splints are being slowly deflated, it is noted that color is returning to the patient's right foot and pulses again become palpable. When the splints are finally removed, a large ring of keys is found in the front pocket of the patient's jeans. It is suspected that the warm air in the emergency department increased gas expansion within the air splints, causing increased pressure on this key ring. The pressure increase was enough to put pressure on the patient's femoral artery, cutting off circulation to his right leg. If the splints had been left inflated for any longer, the patient ran the risk of losing his right leg.

The injuries this patient sustained included fractured ribs of the right chest (causing the pneumothorax), a fractured pelvis, a ruptured spleen, a small liver laceration, fractured left femur, and a closed fracture of the right tibia and fibula. He is taken to the operating room for repair of the splenic and hepatic injuries and orthopedic stabilization and subsequently transferred to the trauma ICU. During his ICU stay, he develops respiratory distress syndrome but is eventually removed from the ventilator and extubated after six days. His other injuries are stabilized and the patient does well.

Discussion

This patient required astute assessment by the transport crew to safely transport him to the trauma center. The conditions at the logging camp did not allow for a complete assessment of the patient and interventions had to be based on the mechanism of injury and the history taken by the EMT at the scene. During transport, the patient's blood pressure dropped, a sign of significant blood loss. As no blood products were available, the team could only support his volume with crystalloid solution. Due to the short length of the trip, this was adequate for this patient.

The other significant complication that could have been devastating to this patient's long-term functioning was the loss of pulse in his right foot. If the pressure on his femoral artery lasted longer, he may have lost his leg to amputation. Equipment should be checked continually for proper functioning to prevent these untoward complications from developing during transport.

PEDIATRIC PATIENT

Transporting the pediatric patient offers a unique set of challenges for the transport crew. Patient size is an advantage, as children weigh less and are more easily moved from one place to another. However, because they are small, children are at risk for more rapid decompensation, without the reserves to help them tolerate the stressors of transport.

Hypoxia develops more rapidly in the pediatric patient. Children have smaller vital capacities and a smaller surface area for gas exchange. An additional complicating factor can be that the child will refuse to utilize an oxygen mask. This potentiates the hypoxia as well as increases the risk of combativeness that is precipitated by hypoxia. If a child refuses a mask, oxygen tubing can be held in front of the child's face and oxygen blown at his oral and nasal airways.

The child's gastric cavity is relatively small; therefore, the child is more prone to complications of gastric gas expansion. Gastric and bowel function are irregular, and it may take a long period of time for food to pass into the bowel, increasing the risk of aspiration. Most pediatric nasogastric tubes available do not have a sump attached; these tubes can clog and suction is more difficult to apply. Occasionally flushing the tube with a small amount of water will assist with emptying the gastric cavity.

Pediatric patients are mouth breathers, which predisposes them to dry mucous membranes. The dry environment in a pressurized aircraft will potentiate this problem. For example, a child with respiratory syncytial virus who has thick tenacious mucous will have increasing difficulty in clearing secretions in this type of transport. Instilling saline into the nasal and pharyngeal passages will assist in thinning the secretions and opening the airways.

Children have a large body surface area to body mass ratio. This predisposes the child to increased evaporative heat losses and subsequent hypothermia. Transporting a child in a cool environment will enhance hypothermia development, and it is crucial that efforts are made to keep the child warm. With the large surface area of the head, placement of a stocking cap is quite successful in keeping the child warm. Rescue-type blankets can be utilized. However, with the large radiated heat loss a child produces, it is easy for the child to become overheated while wrapped in such a blanket. If a rescue blanket is used, it should be placed over the blankets that cover the child, and the edges should not be tucked in around the child.

Children are prone to the same effects of acceleration and deceleration forces as adults. The advantage of transporting a child is that their position can be more easily changed within the confines of the transport vehicle, including elevating the head of the child during landing (deceleration) to limit these forces on intracranial pressure.

Immobilizing the pediatric patient is often challenging, as the child may be too small to fit within the approved stretcher securing belts. Therefore, the crew members should be inventive in their immobilization of the child. Restraining devices need to be secure enough to provide for the safety of the child, while at the same time, not compromising the child's cardiovascular function. Restraining devices that are too tight across the chest of a child can hinder respiratory function and should be avoided. One method of transporting the very small child is to utilize a child's car seat. This offers two advantages. First and foremost is that the child is well secured and safe in the car seat. Secondly, most children feel comfortable in their car seat and may be more cooperative with this increased sense of security.

Noise, vibration, and motion sickness present the same complications in the pediatric patient as are found with adults. Providing diversionary activities to a child may help remove some of these stressors. Fully explaining all noises and procedures to a child may also reduce their fear and anxiety.

Ensuring adequate oxygenation of the child may require that the patient be intubated prior to departure. The challenge of intubating children in a controlled environment is increased many times in the transport environment and should be avoided at all costs. Insertion of a nasogastric tube may be at the discretion of the transport crew; consideration of the child's condition and time since the last meal can be included in the decision-making process. Ensuring that the child has at least one good IV line should be undertaken. Providing the young child with dextrose-containing maintenance fluids will prevent hypoglycemia from developing in transport. Keeping the child warm with hats and blankets will often provide comfort to the child. Transporting with the child's own blanket can also help keep the child warm and provide a sense of security. When placing the child on the transport stretcher, location of the safety straps should be double-checked to prevent placement over the child's chest wall.

Neonates often require transport when born prematurely or when diagnosed with congenital abnormalities. These small individuals are predisposed to hypoxia, hypothermia, and fluid overload states. Specialty-trained neonatal nurses are commonly utilized in these transports as their expertise allows them to carefully monitor the child and the effects of transport on that child. The use of a transport isolette unit provides the child with a safe, warm environment that can limit the harmful effects of transport.

Transporting children requires that the transport personnel be aware of the unique anatomic and physiologic variances of children. With consideration of these special needs, children can be safely transported long distances with minor impact upon their condition.

Pediatric Case Study

Patient F is a boy, 5 years of age, who was found unconscious by his mother after an undetermined amount of time. At his side were an empty bottle of children's acetaminophen tablets and an empty bottle of children's vitamins. EMS responds and transports the patient to the local hospital. He is intubated and placed on a ventilator with 100% oxygen; an IV line is started and blood is drawn for toxicology screen. His mother estimates that there were about 20 acetaminophen tablets and 25 vitamins ingested. The emergency department staff evaluates the bottles, and concern arises because the vitamins contained iron, increasing the risk of iron overdose.

While further efforts are underway to stabilize Patient F, arrangements are made to transport him to the referral medical center, which subspecializes in pediatrics. While awaiting the transport team, gastric lavage is performed, and when completed, the patient receives acetylcysteine down the lavage tube. Throughout the interventions, he remains comatose with occasional weak gasping breaths.

When the transport team arrives, they ask for a chest x-ray and a set of arterial blood gas (ABG) measurements. The chest x-ray shows no evidence of aspiration; the ABG results on 100% oxygen are pH 7.21; PO_2 of 85; and PCO_2 of 54. Based on these results, the team continues the oxygen at 100% but increases the rate of ventilations to 40 (from 30) breaths per minute. The lavage tube is left in place and a Foley catheter is inserted. Patient F's vital signs remain stable, although his blood pressure is on the low side of normal at 88/62 mm Hg.

Prior to departing, the team allows the mother and father to spend time with the patient. The mother asks repeatedly if she can accompany the team. However, due to the confines of the helicopter, this is not possible. The team provides her with as much information as possible about the receiving hospital, including telephone numbers, maps, and plans for admission. As the team leaves, the mother becomes distraught and has to be held back by her husband and other members of the emergency department.

In transport, Patient F's systolic blood pressure drops to 76/42 mm Hg. The team suspects that he is beginning to suffer an acute GI bleed secondary to the iron overdose. However, because this cannot be confirmed, they intervene within the capabilities of the transport, which involves increasing fluid administration. No blood products are available to the team at this time. After three fluid challenges, the patient's blood pressure drops to a palpable level of 50 mm Hg. The fluids are run wide open, and albumin is administered.

During the last few minutes of the flight, the pilot is in contact with the receiving hospital and is able to pass along a message that the patient is in acute need of blood products. Within minutes, the helicopter lands and Patient F is admitted to the emergency department, where the waiting blood is infused. After four units of blood, his blood pressure increases to 78/54 mm Hg.

As the patient is being stabilized in the emergency department, an additional set of ABGs are obtained, and the results are pH 7.15; PO_2 of 76; and PCO_2 of 46. Sodium bicarbonate is administered on a per kilogram basis. Shortly thereafter, Patient F sustains a tonic-clonic seizure. The seizure lasts approximately five minutes after receiving doses of both diazepam and phenobarbital. He is stabilized and transferred to the pediatric ICU.

After four days, his neurologic status improves and he is arousable. He is eventually discharged; however, he continues with neurologic deficits. With intensive rehabilitation, his long-term outcome is hopeful.

Discussion

During the transport of Patient F, his condition worsened, but not because of the stressors of transport. He tolerated the transport complications well, his oxygenation status had been optimized prior to his departure, and he was well-prepared for the transport. However, one of the life-threatening sequelae of iron overdose is GI bleed, and it was suspected that this was the cause of his hypotension in the transport. As this is a well-known complication of iron ingestion, it may have been worthwhile to obtain two or three units of typed, cross-matched blood prior to departure to accompany the patient in transit. However, this was not considered, and the team was able to support Patient F with fluids during the transport. Fortunately, the transport was not a lengthy one; a longer transport may have seen this patient arrest due to significant blood loss.

ELDERLY PATIENT

Evidence Based Practice Recommendation

Adult trauma victims older than 55 years of age are at increased risk for injury and death, and low-impact mechanisms (e.g., ground-level falls) might result in severe injury in this population. The National Expert Panel on Field Triage concluded that advanced patient age should lower the threshold for field triage directly to a trauma center.

https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6101a1.htm

Last Accessed: July 8, 2019

Level of Evidence: Expert Opinion/Consensus Statement

The increased incidence of acute and chronic illnesses in the elderly makes them frequent candidates for transport. For many years, when the elderly became sick, they remained at their local healthcare facility. However, as more sophisticated medical therapies have been developed and are being utilized in the elderly population, these patients are being transported. The multitude of health problems in this population increases their risk for developing complications during transport.

With advanced age comes an increase in underlying disease processes, which should be considered when assessing the elderly patient. A decrease in pulmonary compliance and total lung surface area enhances the risk of hypoxia. Coupled with pre-existing poor respiratory function, elderly patients need aggressive therapies to prevent the problems of hypoxia. Confusion, a sign of developing hypoxia, is often misinterpreted as senile dementia and therefore determined to be acceptable. The transport team has a short interaction with the patient and is not able to fully assess the patient's neurologic status. An accurate history regarding the patient's status from the referring hospital staff will assist the transport members in precisely assessing changes in the patient's condition.

The problems of gastric gas expansion are commonly not reported by the elderly patient, as abnormal bowel function and increased gastric gas are common to this population. Dehydration can potentiate a pre-existing contracted fluid volume state in the patient. It is imperative that adequate fluids are provided, while avoiding fluid overload states. Often fluid status is difficult to assess in the elderly patient, and this difficult assessment is increased in the transport environment. If the ability to assess heart and lung sounds is lost, other parameters, such as skin turgor, blood pressure, and urine output, can be utilized as indicators of fluid status.

The loss of subcutaneous tissue that occurs with aging predisposes the patient to hypothermia. The patient should be kept warm with blankets, clothing, and hats. Limiting out-of-hospital time will decrease the environmental changes that a patient experiences in transport. The better stabilized the patient is prior to transport, the more efficient the transport process.

As the vascular system stiffens, cardiac return and output become compromised. Peripheral circulation decreases, and the ability to withstand acceleration and deceleration forces is diminished. Significant fluid shifts can compromise both cardiac and respiratory function. Additionally, the patient's protective mechanisms are less adaptive, preventing self-protection measures. Positioning the patient to diminish these effects is beneficial. The head of the stretcher should be elevated if possible, and during acceleration, the feet can be placed on pillows.

A unique challenge in the elderly patient with pronounced curvature of the spine is immobilizing the patient on a backboard, should a spinal column injury be suspected. This increased curvature prevents the patient from being secured in a position of good cervical alignment. Additionally, this curvature increases the risk of pressure sore development in areas that are not normally at risk for this complication.

Immobilizing the elderly patient also increases the risk of the patient developing poor venous return and edema formation. Stabilization measures can include the application of antiembolism stockings to assist with circulatory support in this patient population.

While it may seem that diminished hearing and eyesight may be an advantage in reducing noise and vibration input, the opposite is true. A patient who cannot fully comprehend the environment will become increasingly confused and disoriented. The patient may not have heard the briefing offered by the transport crew. Elderly patients' pride may prevent them from admitting to this deficiency. Continual reorientation and explanation can help lessen this confusion.

Elderly patients also have a decrease in both the primary response and cellular immunity that acts to protect them from infection. While this is not a significant problem in transport, it should be considered and all interventions should be performed with this concept in mind. Minimizing the risk of infection is formidable in the transport environment, as handwashing is not feasible and the disposal of contaminated items is not possible. Limiting the patient's exposure to potentially infectious situations should be considered at all times.

Stabilizing the elderly patient for transport is quite similar to that for other patients. Supplemental oxygen should be administered, IV lines should be started and well-secured, and Foley catheter and nasogastric tube placement should be considered. Keeping the patient warm and in a position of comfort will improve the patient's ability to withstand complications as well as provide a sense of security. Optimum long-term outcomes of the elderly are less frequent than in younger populations; therefore, it is crucial that the family members be allowed time with the elderly individual prior to transport. The referring hospital personnel can include these individuals in preparations for transport to provide the family members with a sense of being able to do something for their loved one.

Transporting the elderly patient is not tremendously difficult. However, when the patient does decompensate in transport, it is important that the transport crew be aware of the medical-legal aspects of their care when determining what interventions will be utilized to further stabilize the patient. Awareness of the patient's wishes and advance directives should be an important part of the medical report given by the referring hospital personnel to the transport crew.

Elderly Patient Case Study

Patient G is a man, 70 years of age, who requires transport to a hospital with ventilator capabilities. He is treated at the local 32-bed hospital in his home community for recurrent pneumonia. On his third return trip to the emergency department, he sustains a respiratory arrest and is resuscitated. However, this hospital does not have an ICU, nor are the staff trained in caring for a patient on a ventilator. Therefore, arrangements for transport are made.

The nurses caring for Patient G have previously prepared many patients for transport. They make sure that Patient G has a nasogastric tube and a Foley catheter inserted, and they keep him well-covered with blankets from the warmer. An IV line placed during the resuscitation appears to be functioning without difficulty, and fluids are infused at a to-keep-open (TKO) rate. Patient G continues to be ventilated by the respiratory therapist with 100% oxygen. Finally, the patient's chart, x-rays, and laboratory results are compiled to give to the transporting team.

The transporting team arrives to find Patient G obtunded but responsive to painful stimuli. Arterial blood gas measurements are obtained and reveal a pH of 7.5, PO_2 of 88, and PCO_2 of 24. Based upon these results, the respiratory therapist is instructed to slow the rate of ventilations to 20 per minute. The patient's history is reviewed and includes diabetes mellitus, controlled with 20 units of neutral protamine Hagedorn (NPH) insulin every day, an anterior wall myocardial infarction sustained four years ago, and a history of hypertension, controlled with antihypertensives (although his wife reports that the patient is noncompliant with these medications as he feels "draggy" all the time). At the present time, the patient's blood pressure is reported to be 110/62 mm Hg.

The patient's chest x-ray is reviewed and reveals a large consolidation in the left lower lobe. No other abnormalities are reported. Oral antibiotics had been ordered five days previously, and a single intravenous dose is administered before the arrival of the transport team.

The transport team compliments the referring hospital staff on their stabilization measures and prepares to depart with the patient. The patient's wife is allowed in to see her husband and she begins to cry at his bedside. One of the referring hospital staff remains with her throughout her visit and continually provides psychosocial support. The transport team promises to notify her of his safe arrival and estimates the length of transport to be approximately one hour.

After take-off in the airplane, the patient develops ventricular ectopy as noted on the cardiac monitor. The team assumes that this is caused by increasing hypoxia, enhanced by the previous myocardial infarction. As the patient is on the ventilator on 100% oxygen, the hypoxia can only be managed by changing the patient's position to maximize gas exchange. He is turned onto his right side to improve his ventilation and perfusion ratio. However, the ectopy continues and the patient is started on an amiodarone drip.

During the ectopy, the patient's blood pressure drops to a systolic pressure of 88 mm Hg. The team increases the IV fluid rate, and immediately the IV becomes nonfunctional. As the patient only has one IV line, this means that the amiodarone (Cordarone) is also discontinued. While numerous attempts are being made at IV line placement, the frequency of the ectopy increases. IV line placement is unsuccessful up to this point, secondary to the patient's contracted fluid status and the multiple attempts that had previously been made during his arrest at the referring hospital.

While the second crew member attempts to start an IV line, the patient sustains a cardiopulmonary arrest. The team begins resuscitation efforts per advanced cardiac life support protocols, including administering medications via the endotracheal tube. The patient continues in ventricular fibrillation for the remainder of the flight and the transport team chooses to discontinue resuscitation efforts after 45 minutes. The difficulty in making this decision to discontinue treatment is that the team has no diagnostic capabilities available to them to determine the cause of the arrest. While it is assumed that this was caused by hypoxia secondary to the pneumonia and enhanced by the previous myocardial infarction, the team cannot be sure. However, after 45 minutes, all efforts available to them have been undertaken and the team has no further interventions at their disposal. Shortly after this, the airplane lands at the airport and the medical examiner is notified of the patient's death.

The final task required of the transport team is notification of the patient's wife of his death in transport. She is assured that all efforts were performed to prevent his death and that he did not suffer during these efforts. She thanks the team for their efforts to save her husband's life and hangs up the telephone.

Discussion

This case presented the difficulties in transporting a patient with a multitude of health problems in an environment with limited resources. The patient's outcome was tenuous before the transport, and was further compromised in the transport environment. However, his condition at the time of the transport was such that he could not have remained at the referring hospital due to their limited resources. Therefore, the transport needed to take place, the risks being an inherent part of the transport.

The transport team did not take the time to start another IV line; had they done so, the patient may have survived the transport, as the arrest may have been avoided. Any patient who has previously arrested and requires transport should have at least two IV lines in place. The patient's IV line had appeared to be functioning; however, it was at a TKO rate, which is not a true test of a line's patency.

The decision to not place a second IV line may have been based on the fact that the referral hospital had been working hard at stabilizing the patient and the transport team did not want to offend them. While this line of thinking is polite, the error of their judgment is obvious. Placing a second line could have been performed without offending the staff by simply explaining the need for a second line, should the first one malfunction. The referral hospital staff seemed interested in helping to stabilize the patient and would most likely have viewed this explanation as a learning experience. Hopefully, the transport team will never make this mistake again. And while the transport team's interventions may be questioned, the death of this patient cannot be blamed on their error in judgment.

HIGH-RISK OBSTETRICAL PATIENT

Evidence Based Practice Recommendation

According to the National Expert Panel on Field Triage, all pregnant women at greater than 20 weeks' gestation who suffer trauma should be transferred to a trauma center or hospital capable of timely and thorough evaluation and initial management of potentially serious injuries.

https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6101a1.htm

Last Accessed: July 8, 2019

Level of Evidence: Expert Opinion/Consensus Statement

Transporting the high-risk obstetrical patient involves the stabilization and transport of two patients, the mother and the fetus. The sudden, precipitous delivery of the fetus is always a possibility and should be prepared for. If possible, delaying the delivery would be preferable to all individuals involved in the transport. Contraindications to transport, including acute fetal distress, uncontrolled maternal bleeding, and imminent delivery, may postpone the transport until such time that both the mother and fetus (or newborn) are stabilized.

During pregnancy, increased oxygen consumption occurs, predisposing the woman to hypoxia during times of stress. Hypoxia causes uterine irritability and predisposes the patient to premature labor. For the patient being transported for premature labor, this is a significant consideration. Providing supplemental oxygen throughout the transport and positioning the patient in the left lateral decubitus position will enhance the patient's oxygenation status. If exposed to hypoxia for a short duration, the fetus will experience minimal effects. However, as maternal hypoxia increases, fetal distress will develop as evidenced by a decrease or increase in fetal heart tones.

Gastric gas expansion causes pressure on the diaphragm, which is elevated during the third trimester. This leads to the development of dyspnea, and further increases the risk of hypoxia development. Gastric gas expansion can also place pressure on the uterus, increasing uterine irritability. Insertion of a nasogastric tube to suction will help relieve this development as well as reduce the risk of vomiting during turbulence.

During pregnancy a woman develops a 40% to 50% increase in circulating blood volume, although this is mostly an increase in plasma. Dehydration can cause a woman to become volume depleted rapidly, and volume depletion predisposes the uterus to preterm labor. Increased fluid volumes are required during pregnancy, and this volume should be increased even further during transport.

Of all patient types transported, the one who prefers the decrease in ambient temperature is the pregnant patient. Massive vasodilation occurs during pregnancy so the woman is continually complaining of being warm. This cool environment has little effect upon her physiologic functioning and will increase patient comfort. However, should the fetus be delivered, this cool environment can be harmful to the neonate's outcome. The neonate should be immediately dried and wrapped in blankets to help maintain body temperature.

Fluid volume shifts associated with acceleration and deceleration forces can lead to a decrease in uterine blood flow. Physiologically, the uterus is considered a nonessential organ in the body's response to shock and low-flow states, thereby leading to fetal distress when circulating volume is shifted towards the core circulation and away from the uterus. Placing the patient in the left lateral decubitus position will improve venous return and the ability to withstand these forces.

Most stretcher securing devices are designed to function properly when the patient is in the supine position. The pregnant patient who is transported in the left lateral decubitus position is more difficult to safely secure to the stretcher. Additionally, if the stretcher is located on the right side of the transport vehicle, the patient will be facing away from the transport crew during the transport. This obviously presents difficulties in assessing the patient. Turning the patient may seem the obvious answer; however, this is nearly impossible in many helicopters and airplanes used in air transport. Therefore, immobilizing and securing the pregnant patient presents one of the more challenging problems in transport.

A decrease in gastric motility that occurs during pregnancy predisposes the patient to vomiting with motion. This can be avoided with the insertion of a nasogastric tube, as previously discussed. Patients with pregnancy-induced hypertension (toxemia of pregnancy) are at increased risk of experiencing nausea and vomiting with motion. Hypertension, which can accompany vomiting, is to be avoided in these patients, and efforts to reduce this untoward complication should be considered a high priority.

Noise and vibration also can compromise the patient with toxemia of pregnancy. The patient may be increasingly sensitive to environmental input, predisposing her to seizure development. Reduction of noise with ear plugs can help reduce this input and limit her exposure to increased risk. Dimming the cabin lighting will also help in reducing the risk of seizure activity, although this may hamper the transport team's capabilities in accurately assessing patient color.

Stabilization prior to transport requires accurate assessment of the patient's status and interventions to maximize her physiologic functioning. High-flow oxygen, preferably by non-rebreather mask, and appropriate management of her fluid status will heighten her ability to withstand these stressors. Medications to control preterm labor can be instituted and continued throughout the transport. Seizure precautions should be initiated prior to transport and antiseizure medications should be readily available.

Delivery of an infant is also a consideration. The transport crew should have sufficient training in the delivery of an infant, as well as training in stabilization measures necessary to support the life of the child. Delivery of a child requires that the transport be diverted to a closer facility if additional stabilization measures are required for the infant. Knowledge of the resources available en route is imperative during the pretransport planning. Appropriate size equipment for airway and circulatory management should be easily accessible in the transport environment; this should include, but not be limited to, infant size laryngoscope blades, infant endotracheal tubes and suction catheters, infant intravenous catheters, and intravenous fluids used for neonates. Methods of maintaining the child's body temperature should be available, including rescue blankets and stocking hats.

The emotional impact of transport on the high-risk obstetrical patient is extreme. Time for interactions with other family members should be made available. The woman's original birth plan is no longer a reality and the patient and her family should be assisted in understanding the necessity of transport. While most individuals want the transport to occur because they believe that it is best for the outcome of the child, removing the patient from her loved ones remains difficult. The family that is left behind needs assurance that they will be notified immediately upon the patient's arrival at the receiving facility. If the patient's condition warrants, she can be the one to place this important telephone call.

During the transport itself, it is difficult to fully assess the patient. As mentioned earlier, she may be facing away from the transport crew. The ability to hear fetal heart tones with a fetoscope is negated by the noise inherent in the transport vehicle. An obstetrical Doppler monitor should be considered an essential piece of equipment to allow for the monitoring of fetal heart tones. Fetal heart tones are the only indication of fetal status available and are crucial to ascertain, at a minimum of 15-minute intervals.

Preparing for a high-risk obstetrical transport requires a great deal of planning. Equipment should be readily available, training should be current, and the transport crew should be prepared to deal with all consequences. Fortunately, the majority of obstetrical transports occur without utilizing all of this preparation. When the patient is stabilized appropriately and thoroughly, the majority of transports occur smoothly.

High-Risk Obstetrical Case Study

Patient H is 38 years of age and has developed preterm labor at 31 weeks' gestation. Tocolytic therapy has been unsuccessful at discontinuing her labor, and she is to be transported by air to a high-risk obstetrical center with the capabilities for delivery of a high-risk neonate. Patient H's history includes a previous cesarean delivery two years ago for uterine atony. She has a two-year-old girl and a husband who is very involved in the child's care.

In preparing the patient for transport, the referring hospital personnel start Patient H on oxygen by face mask. Magnesium sulfate is infusing at a rate of 3 g/minute in an effort to control or stop her labor; a new drip is made so that there will be a sufficient amount of medication to last the length of the transport. Additionally, Patient H is receiving lactated Ringer's solution at a rate of 75 cc/hour. Her husband remains with her throughout the preparation, offering her emotional support.

When the transport team arrives, they review Patient H's history with her and with the referring hospital staff. Patient H is well-informed of the reason for the transport and wants to get to a facility that can provide intensive neonatal support, if needed. Prior to departing the hospital, the transport team places Patient H on a non-rebreather mask to increase her oxygen concentration delivery. She is placed on the stretcher in the left lateral decubitus position and fetal heart tones are monitored prior to departure from the hospital. Fetal heart tones remain at 120 to 130 beats per minute.

During transport Patient H's vital signs remain stable, a Doppler monitor is utilized to monitor the fetus, and after 20 minutes, the patient appears to fall asleep. Thirty minutes into the flight, the transport crew notices that Patient H's respiratory rate has dropped to a rate of 6 breaths per minute. They immediately start assisting her ventilations with a bag-valve-mask device. Her vital signs are obtained; her systolic blood pressure has dropped 20 points. Fetal heart tones are initially not heard; after repositioning the patient, they are measured at 100 beats per minute. At this point, it is apparent that both the mother and fetus are in acute distress and a decision regarding interventions has to be made.

The team continues to hand ventilate the patient with 100% oxygen; after seven to eight minutes, the fetal heart tones increase to a rate of 118 beats per minute. The patient's respiratory rate remains at 6 breaths per minute, and the team continues to ventilate her at a rate of 25 per minute with 100% oxygen.

The team is now 20 minutes from the receiving hospital and the transport continues to its original destination. The patient requires continuous ventilatory support during the remainder of the transport. Fetal heart tones continue to fluctuate between 110 and 120 beats per minute.

Immediately upon arrival at the receiving hospital, Patient H is intubated and placed on a ventilator. She is arousable at this point, and showing signs of acute apprehension. Further studies reveal that her magnesium level is toxic, which caused her ventilatory failure. The magnesium drip is discontinued and she remains on the ventilator until her magnesium level is within normal limits, at which time she is successfully weaned from the ventilator.

When the magnesium drip is discontinued, her contractions increase in frequency and intensity. Other therapies are unsuccessful at controlling her contractions, and her membranes rupture. Within two hours of arriving at the receiving hospital, Patient H delivers a 1,000-gram baby boy. The infant is immediately resuscitated by the neonatal team and transferred to the neonatal intensive care unit (NICU). The baby boy does well and is released when weighing slightly more than 4 pounds.

Discussion

The referring hospital had well stabilized Patient H for the transport, with the exception of obtaining a magnesium level. The transport team neglected to look for this result in the patient's chart, and this set up the course of events leading to the patient's ventilatory failure. Additionally, the healthcare providers should have been monitoring the patient's deep tendon reflexes, as weakened reflexes indicate impending magnesium toxicity. Although this would have been difficult to perform in transport, the team should have attempted to obtain this assessment parameter.

Fortunately, the outcome of this transport was excellent. The patient was successfully ventilated when the need arose, and the fetus responded to this ventilatory support. Had the transport been longer, the team may have elected to attempt an intubation in the aircraft. Successfully mask ventilating a patient for a long period of time is difficult within the confines of the transport vehicle and tiring for the transport crew; however, intubation is also a challenge in this environment.

The transport team appeared not to consider that the patient may have been magnesium toxic. Had this been considered, they could have discontinued the drip and switched to another tocolytic agent. The most serious consequence of this action would have been an earlier delivery of the fetus, possibly during the transport itself. While other tocolytic agents may have been unsuccessful in terminating the preterm labor, the need to discontinue or slow the rate of the magnesium infusion was indisputable.

The successful outcome demonstrates the appropriateness of this transport. Without accessing such a facility prior to delivery, the infant would have been subjected to the stressors of transport as a neonate requiring NICU care and may not have tolerated the transport as well as he did while remaining in utero.

These case studies have demonstrated a number of developments that can occur in the transport environment. While some of the complications may have been avoided with more intensive stabilization, the outcomes of the patients presented most likely would not have changed. Appropriately stabilizing the patient should be considered one of the most important steps in transporting the sick or injured patient.

7. DETAILS INVOLVED IN THE TRANSPORT OF PATIENTS

GENERAL CARE IN TRANSPORT

As discussed, continual assessment and interventions during transports are performed to keep the patient as stable as possible. The transport crew's responsibilities are performed with limited resources in a less-than-optimal environment. The advantage of transport is that there are usually no other distractions, and the patient is the crew's sole medical responsibility.

To maintain patient stability, the transport crew functions under standing transport protocols as well as physician orders. The interventions that can be undertaken include, but are not limited to, airway stability, suctioning, fluid management, performing advanced life support measures, administering medications, and either chest tube or flutter valve insertion. Monitoring the patient involves the utilization of a cardiac monitor, pulse oximeter, and capnography. Doppler monitors are employed to assess pulses when auscultation is difficult. Analysis of blood results is possible utilizing transportable bedside testing devices.

Vital sign assessment should be completed at frequent intervals to allow for early detection of patient deterioration. The patient's level of consciousness should be frequently monitored; hypoxia is a common cause of neurologic decline. Fluid intake and output should be frequently checked, as gas expansion occurring in air transport can cause changes in the fluid infusion rates.

The transport team is involved in the stabilization of the patient as previously discussed. The stressors of transport are reviewed and the patient stabilized to minimize these effects. During transport, the team should continually assess for the effects of these stressors and intervene as necessary. Releasing a small amount of air from the air splints during ascent in air transport will need to be followed with inflation during descent. Prevention of these untoward complications is the goal the crew works to attain.

All care during transport should be documented. The transport form should become a permanent part of the patient's chart at the receiving facility. The receiving staff should be familiar with its design in order to obtain information regarding the patient's response to transport. Any unusual events should be noted and the patient's response to these events recorded.

Throughout the transport, the team should be prepared to deal with the worst possible outcome. Without ancillary help or extra equipment available to the crew, they should be able to act and intervene rapidly and efficiently within the confines of their working environment. In unforeseen emergencies, when sophisticated medical equipment and personnel are critical, diversion to a closer facility may be necessary. It is important that the crew knows the location of these facilities to prevent unnecessary delays.

COMMUNICATION

The communication loop begins when the transport is initiated. It is complete when the report has been given at the receiving hospital and the documented paperwork is integrated into the patient's chart. This process includes a number of individuals, and effective communication at each level is imperative. A break in this process can increase the risk of complications.

When a call for transport is placed to a transport program, whether it be air or ground transport, information regarding the patient's status is shared and should be based on physician-to-physician contact. Although direct physician communication may take place at a later time, the medical control individual responsible for the transport is taking on the legal ramifications mandated by law. Once the patient's status has been provided, the requirements for pretransport stabilization should be communicated to the care providers. The transport team should be informed of any special needs that the patient will require. This may include the use of specialized equipment, which is not normally carried in the transport vehicle. The transport team should receive a complete report from those individuals who are providing the initial stabilization measures to the patient. During transport, the transport team may or may not be in direct contact with their base station. The team is directed to function under standing orders and written protocols. Should the team need to deviate from these protocols, accepted standards of practice and safe and reasonable actions should be employed.

Upon arrival at the receiving facility, the transport crew should provide information about the patient's condition from the time of the initiating event to the time of arrival of the patient at the receiving hospital. Much of this information is secondhand, so the communication process should be flawless to ensure that important pieces of information are not lost. Finally, all information should be fully documented as a permanent form of communication.

As noted, before this process is complete, the patient's family and the referring facility should be notified of the safe arrival of the patient. Only after all involved persons are notified is this loop considered complete.

Communication techniques and technology are too extensive to be covered here; the reader is referred to a number of excellent references if more in-depth information is desired. Regardless of the technology utilized, every effort should be undertaken to protect the patient's confidentiality based upon the Health Insurance Portability and Accountability Act (HIPAA) requirements. The patient's name should not be used, and other identifying features should be avoided. This is especially difficult during an incident with a high-profile patient or during a media event.

MEDICAL CONTROL

All transport programs have a medical control officer. The organization of this control varies from system to system. On-line medical control is the direct communication between the transport personnel and the physician (or physician-surrogate) via radio or telephone for the purpose of providing orders for patient care.

Off-line medical control includes those administrative functions that are necessary to ensure the quality of care. Each medical control officer is a physician who is directly responsible for the transport crew and their actions. It is the medical control officer's responsibility to ensure proper training, orientation, development of protocols, and ongoing continuing education.

Most transport programs have recurring "run reviews" in which the transport is reviewed for appropriateness, timeliness, and care delivered in transport. These run reviews are directed by the medical control officer and assist in providing ongoing education for the crew members. Additionally, this review allows for a critique of current protocols and can provide the impetus for change that may be necessary to meet the changing technology of medical care.

SPECIFICS OF GROUND TRANSPORT

Ground transports are unique in that they can be initiated by the general public through emergency medical care systems, such as the 911 system. Air transports are generally initiated by healthcare providers after initial evaluation of the patient's status. Public request for medical care often puts the transport crew members at a disadvantage, as the information they receive may be inaccurate and/or incomplete. Therefore, ground transport crew members should perform astute assessments while under the watchful eye of the patient's family, friends, and the general public. To work in this type of job, the individual should be self-assured about their abilities and confident of their responsibilities.

Emergency medical care systems are well developed in the United States. Patients are often within minutes of being treated by individuals trained in basic life support measures. A tiered layer of response is generally utilized; if the patient's condition warrants more intensive treatment, individuals trained in advanced life support measures are rapidly called to the scene. This system maximizes healthcare resources without wasting limited healthcare dollars. In 2019, the Centers for Medicare and Medicare Services (CMS) introduced the Emergency Triage, Treat, and Transport (ET3) model, a voluntary program in which Medicare will pay participating ambulance suppliers to either transport Medicare beneficiaries to the emergency department, transport to a primary care or urgent care clinic, or provide care at the location. This model is intended to give ground transport and local 911 dispatches greater ability to triage patients, and is designed to prevent unnecessary emergency department admissions, thereby improving quality of care and lower costs [17].

Ground transport may also be utilized in transporting a patient from a small facility to a larger hospital with more sophisticated resources. These transports require personnel with a more advanced level of training; it is important to remember that a patient cannot legally be transported in an environment that does not provide the same level of care as the patient had been previously receiving.

While ground transports do not have to contend with the stressors of altitude changes that occur in air transport, the other stressors (e.g., acceleration, deceleration, prolonged immobilization) remain factors throughout the transport. It is the feeling of many seasoned transport personnel that caring for a patient while going across town in a ground ambulance is equally as difficult as caring for a patient in a helicopter. The constant forward, backward, and lateral movements of both environments make caring for the patient a true challenge.

SPECIFICS OF FIXED-WING TRANSPORTS

Most established transport programs utilize pressurized aircraft for the transport of patients. This pressurization system allows for the maintenance of a reasonable cabin pressure altitude, minimizing the effects of altitude-induced changes on the patient. However, there are still patients who are transported in unpressurized aircraft, and it is these patients who are greatly impacted by altitude changes.

If a patient is to be transported by a fixed-wing aircraft, the patient should be stabilized with consideration of the stressors of altitude. The length of the transport is also an important consideration; the longer the transport time, the longer the exposure to the stressors of altitude and the greater the risk of complications. It is also generally true that the longer the transport, the higher the altitude at which the aircraft will travel, increasing the risks of hypoxia and gas expansion. Each patient should be continually assessed for these risks as they can develop insidiously.

Caring for the patient in a fixed-wing transport is often easier than in other transport environments. The cabin space is larger than in a helicopter, allowing for additional equipment and increased room to maneuver. Many fixed-wing aircraft dedicated to air transport are retrofitted with mechanical ventilators, large oxygen and air tanks, hospital-grade suction, and alternating current (AC) power sources. These aircraft are often referred to as flying ICUs. This sophisticated environment demands that the transport crew has additional training in the use and care of the equipment on board. Many transport programs utilizing mechanical ventilators include a respiratory therapist as a part of the transport crew. This individual is responsible to care for the patient's airway and ventilatory status.

Fixed-wing transports require the use of ground ambulances to transport the patient from the hospital to the airfield and back to the hospital at the receiving end. This system requires good communication with ground-based personnel to prevent unwarranted delays in the arrival of these ground units. Time is of the essence and the ground ambulance should be present to assist with moving the patient in an expeditious manner.

SPECIFICS OF ROTOR-WING (HELICOPTER) TRANSPORTS

One of the most important aspects of helicopter transports is the safety of the individuals on the ground when the helicopter is landing and taking off, which is discussed later in this course. Transporting the patient in a helicopter is a challenging and difficult responsibility. Access to the patient is limited; often only the patient's upper torso and head are accessible. Thorough pretransport stabilization is critical if the patient is to be transported safely. While the length of transport is generally short (as compared to fixed-wing or ground transports), the patient is at risk during the entire transport.

The effects of altitude on the patient can be minimal to extensive. As mentioned, helicopters are not pressurized. Therefore, if the helicopter must ascend in altitude to clear mountain passes or other obstacles, the patient will experience both hypoxia and gas expansion. Generally, the pilot of the helicopter will choose a flight path that has minimal altitude changes, thereby limiting patient complications. However, care in transport requires that the transport crew be aware of these risks and intervene as necessary should they become a factor.

With restricted access to the patient, in-flight care is limited, requiring the crew to perform frequent assessments. Care in-flight is often limited to ABC support, as well as medication administration. Changing patient position and other comfort measures may need to be withheld. However, the crew should remember, as in all transports, that if the patient is anxious and frightened, measures to calm the patient should be performed as part of routine care.

TRANSPORT EQUIPMENT

Statutory law regulates the equipment required in ground transports. In many states these statutes also regulate the operation of air ambulances. The minimum equipment needed for maintaining the stability of the ill or injured patient is listed in Table 3. Additional items can and should be included as the patient's condition and needs dictate. Equipment utilized in the transport environment should meet specific criteria, including but not limited to being: lightweight; portable; easy to secure; easy to clean; able to be utilized with battery backup; able to be used both in and outside the transport vehicle; and able to withstand the stressors of altitude and movement.

Table 3: TRANSPORT EQUIPMENT

Vehicle Equipment

Stretcher(s) with necessary linen

Communication system

Adequate lighting (ability to isolate driver or pilot from lights)

Electrical outlets (110 v AC)

Permanent suction source

Locking IV hooks

Fire extinguisher

Survival gear

Medical Equipment

Oxygen source with regulators and flow meters

Portable suction

Cardiac monitor and defibrillator

Doppler monitor

Infusion pumps

Ventilator (as appropriate)

Pulse oximeter

Equipment Packs

Primary Responder Pack

Airway and Ventilatory Kit

Medication Drug Case

Burn Pack (as patient condition warrants)

Neonatal Pack (as patient condition warrants)

Cardiac Pack (as patient condition warrants)

Obstetrical Pack (as patient condition warrants)

Pediatric Pack (as patient condition warrants)

Trauma Pack (as patient condition warrants)

Source: Compiled by Author

Medical crew members should be familiar with the operation of the equipment in the transport vehicle, as well as be able to repair the equipment should it fail. The crew members should ensure that an adequate supply of disposable equipment is available to last for the length of the transport, with consideration of possible delays that may extend the projected transport time.

All equipment utilized in the transport environment should be easily secured. Equipment packs made of soft material are generally utilized for disposable equipment. If the equipment requires a power source, a backup battery source should be available if the power fails. The team could utilize hand-powered devices, such as resuscitation bags for ventilating the patient, if a ventilator failure were to occur. All equipment should be protected from electromagnetic interference. If not, radio transmissions may render the equipment nonfunctional.

In air transport, equipment weight is also an important factor. Placement of heavy items is at the discretion of the pilot-in-command; the weight and balance of the aircraft should be maintained for safe performance. Equipment that is permanently secured to the aircraft (e.g., ventilators, suction units, oxygen tanks) are placed in a position offering the crew some leeway in the placement of other disposable equipment packs.

It is important that the oxygen source in the transport vehicle be operating appropriately. The volume remaining in the tanks should be checked prior to each departure. These tanks can be replaced with full tanks to ensure an adequate oxygen supply throughout the transport. Attachments for the humidification and warming of the oxygen are available and should be utilized as the patient's condition warrants.

Altitude impacts flow rates of oxygen cylinders. Table 4 demonstrates this effect on flow rates. If transporting the patient by air, it is important that the crew utilize this information when calculating oxygen supply. If standard sea level flow rates were utilized, the oxygen supply would run out before the calculated time, putting the patient at significant risk.

Table 4: ALTITUDE EFFECTS ON FLOW RATES

Ohio Oxygen Flowmeter (Liters/Minute)

Flow Rate at Altitude (Calculated)

2,000 ft

5,000 ft

8,000 ft

2

2.1

2.4

2.6

4

4.2

4.7

5.3

6

6.3

7.1

7.9

8

8.4

9.4

10.6

10

10.5

11.8

13.2

12

12.6

14.1

15.8

Source: Compiled by Author

Other transport equipment that may be utilized includes infusion pumps, Doppler monitors, pulse oximeters, and cardiac monitors. Monitoring of oxygen saturations and end-tidal carbon dioxide levels is critical when auditory cues are diminished. The crew should know the limitations of each piece of equipment and not depend solely on the equipment but rather on their assessment of the patient when making decisions regarding interventions.

When equipment packs are prepared, the crew generally packages items together to maximize the efficiency of their actions. For example, a nasogastric tube is packaged with an aspirating syringe, gel for insertion, adapters for connecting the tube to the suction source, as well as tape. When a nasogastric tube is to be inserted, the team has everything together in one package and does not need to open numerous packs in search of a piece of equipment.

Medications are usually removed from their standard packaging. The boxes that most medications come in are bulky and, in the event of a respiratory or cardiac arrest, make a large mess in a small place. It is important for the crew to check the medication labels closely, as should be done for any patient anywhere.

Transport packs are usually developed for individual patient needs. Many programs have developed a pack for burn patients, neonates, obstetrical patients, and pediatric patients. Knowing that the patient is 8 years of age alerts the transport crew to the need for the pediatric pack, and this can be loaded on the transport vehicle prior to departure. This limits the amount of excess equipment transported on each and every transport. Additionally, equipment is commonly placed in a backpack style pack so it can be easily carried into and out of remote locations.

8. PRINCIPLES OF TRANSPORT

SAFETY ISSUES

Safety in transport should be the primary concern of all individuals at all times. Most accidents occur during helicopter transfers; however, a high level of risk is associated with all types of transports. Safety concerns should focus on all aspects of the transport, including both patient and crew safety issues. It is imperative that all personnel develop a strict policy to ensure their safety and the safety of others.

Safety restraints should be utilized at all times. This means that the patient should have restraining straps secured throughout the transport and that the crew wears seat belts at all times. Crew members often become complacent about seat belt use, removing the belt during the transport to allow for more movement around the transport vehicle. In an aircraft, the pilot should always ensure that everyone is secured prior to takeoff and landing; it is during the transport when these measures are neglected. Clear air turbulence can cause significant injury to unrestrained individuals at any time during a flight.

All equipment should be secured, and securing devices should be double-checked throughout the transport. Equipment that can present danger to the patient or crew should be placed away from individuals' heads, placing it either near the patient's feet or, preferably, on the floor. Disposable equipment in soft packs will limit the dangers inherent in hard objects.

The crew should brief everyone prior to each departure. The pilot should be informed of the patient's condition, and the patient should be informed of his or her responsibilities in the event of an emergency. Family members who accompany a transport should be briefed as to the location and function of emergency exits and the need to utilize safety restraints throughout the transport.

No smoking should be allowed in or around a transport vehicle. The team should know where fire extinguishers are located and how they work. Crew members should avoid flammable clothing such as nylon and polyester, which, if ignited, can cause deep, full-thickness burns.

The crew should be trained in the proper functioning of emergency exits and emergency procedures. The emergency exits should be clearly marked and should be kept clear of extraneous equipment. Emergency procedures should be practiced on a regular basis as part of continuing education.

The transport crew's first responsibility in an emergency is to themselves and then to the patient. The crew should remain safety conscious at all times. It is worth mentioning that the occupational injury rate for EMS workers in the United States is the highest of any reported to the Department of Labor [14,15].

Helicopter Safety

Helicopter transports create a large amount of interest. Many people assemble to watch a helicopter take off and land. These bystanders should be kept away from danger. A safe landing zone should be established in a clearing that measures at least 75 feet by 75 feet, although most pilots prefer a landing area of a minimum of 100 feet by 100 feet. The landing surface should be solid; sand and gravel should be avoided. The slope of the landing site should be no greater than 8 degrees, otherwise the tail rotor is at risk of contacting the ground. All wires, trees, and other possible hazards should be marked and verbally described to the pilot. Smoke flares are used to assist the pilot in locating the landing zone, but it is imperative that these be removed prior to the helicopter's approach as they may obscure the landing zone and can be blown away, possibly causing a fire. All loose items should be removed from or secured to the landing zone.

When the helicopter is making its final approach, the patient, ground crew, and bystanders should be at least 500 feet from the site and should be directed to turn their backs to the helicopter. This is the hardest rule for bystanders to comply with; they came to watch and they will watch. The rotor wash, created by the rotating blades, causes swirling dust and gravel, posing a hazard to all individuals. Landing in the snow poses a real hazard, as the rotor wash produces a momentary whiteout condition. Additional hazards are created when the rotor wash blows loose items up and around. This can include stethoscopes hanging around a team member's neck, sheets covering the patient, or transport forms.

Helicopters should always be approached from the front, in the line of sight of the pilot. Never approach a helicopter from the uphill side. As rotor blades slow, they drop closer to the ground, possibly causing the decapitation of an unsuspecting person. Finally, approach should only be done once the pilot has indicated that it is safe to do so.

On rare occasions, a "hot" loading or unloading may be performed. This is when the patient is loaded or off-loaded with the rotor blades turning at idle speed. In these instances, all personnel should approach the helicopter in a crouched position. This is only done in cases of extreme emergency; some transport programs prohibit this action in all instances, citing the high risk of injury.

Other hazards of a helicopter include noise, which is measured at 90 to 100 decibels, and wind, which is up to 50 miles per hour. Engine exhaust that is routed out of the back of the helicopter measures 750 degrees Fahrenheit. Most individuals are aware of the main rotor blades that rotate above the fuselage of the helicopter, but the tail rotor at the back of the helicopter is difficult to see when spinning. Injuries commonly occur when individuals approach the helicopter from the rear.

Fixed-Wing Safety

Fixed-wing safety requirements in air transport should meet the same stringent requirements of the FAA regulations under which commercial aircraft function. These requirements specify that all equipment should be secured to ensure that passengers and crew are not injured by flying objects during turbulence or in the event of a crash. Equipment that is not secured to the airframe should be in soft packs and placed on the floor away from the patient and crew. Emergency exits should never be blocked by equipment or extraneous items.

The aircraft should always be approached in a safe manner. Although the hazards are not as great as with helicopters, the exhaust from a jet engine can reach 900 to 1,100 degrees Fahrenheit, causing a significant burn if contact is made with the exhaust or the cowling over the exhaust vent. Propeller aircraft should always be approached from behind the wing to prevent injury from the propeller. Ground personnel who are assisting with the loading and unloading of the aircraft should be trained and briefed regarding safety issues. Weight distribution is critical in aircraft and the ground personnel may not be aware of these requirements.

The pilot-in-command is responsible for the safety of the aircraft at all times. The pilot has the authority to determine that it is unsafe to fly a particular mission in certain weather conditions. This also holds true for rotor-wing transports. In most transport programs, the pilot is not informed of the patient's condition at the time a transport is requested. This relieves some of the stress that may cloud judgment when a life-or-death transport is being requested. The pilot should be free to decline a mission based upon weather or other factors, without feeling guilty for this refusal.

In the event of an emergency landing of an aircraft, all electrical equipment and oxygen must be turned off. If the patient is attached to a ventilator, the patient should be hand ventilated and the ventilator shut down. If time allows, the patient should be protected with extra linen and pillows. The crew should ensure that emergency exits are not blocked and the rapid egress is possible once the aircraft has landed. Once the aircraft has come to a complete stop, the crew should make a rapid assessment of the condition of the patient and other crew members. All personnel should immediately exit the aircraft and move to a safe spot, at least 500 feet away from the aircraft. One of the biggest risks in an emergency landing of this nature is the rupture of a fuel tank, causing an explosion and fire. The team should be well away from the aircraft in the event that this occurs. Once all individuals are safe, a plan should be formulated on how to care for those injured in the crash. The crew should remain with the aircraft unless a road or other public area is easily accessed. It is much easier for rescue teams to locate a downed aircraft rather than a lone individual walking to get help.

In any emergency situation, keeping a clear head and maximizing available resources will assist with a successful rescue. Knowledge of radio codes and emergency broadcast frequencies will help the search and rescue teams find the location of the aircraft in an expeditious manner.

9. MEDICAL-LEGAL ISSUES

Providing patient care in the transport environment encompasses a number of medical-legal issues. Responsibility for the care of the patient is often shared among a number of individuals and institutions, requiring that each one is aware of the other's function and capabilities. Both the transport personnel and those individuals who are facilitating patient transfer should be aware of these requirements to ensure that the patient is transferred in a safe and legal manner.

COBRA/EMTALA IMPACT

As previously discussed, in 1985 the transport of patients was addressed in the Consolidated Omnibus Reconciliation Act (COBRA). Subsequently, in 1995 these regulations were amended as a part of the EMTALA to clarify specific aspects of patient care.

The most significant impact from these regulations is that ever more patients are being transferred to facilities that can provide specialized care. This has increased the number of transports, which has caused a proliferation of transport programs. As these transport programs were developed, the expertise of transport personnel has improved and patients are now safely transported both on the ground and in the air.

Responsibility to Provide Care

Responsibility to provide care is shared among the physicians who are directly involved in caring for the patient. When an interfacility transport is being conducted, the referring and receiving physicians share in the patient's care. This responsibility may also be shared with the medical control officer of the transport program who is directly responsible for the actions of the transport team.

The concept of shared responsibility was developed to prevent referring physicians from transferring patients in a manner that is not suitable to providing care. Prior to joint responsibility, some physicians would order a patient to be transported out of their facility, and arrangements for this transport were made as quickly as possible. The patient would be loaded in whatever transport vehicle was available (in some cases this was a taxi) to ferry a patient across town. Once the patient left the referring hospital, the physician's responsibility was complete. This yielded a situation in which the patient arrived at the receiving facility in worse condition or even possibly dead.

Therefore, to ensure that patients are transferred safely, the responsibility is shared. This requires that the referring physician utilize the most appropriate mode of transport, employing trained transport personnel. The receiving physician should ensure that the patient arrives in as good condition as possible, withstanding the stressors of transport.

The shared responsibility ends when the patient arrives safely at the receiving facility. A notation of their safe arrival should be made in the copy of the patient's chart, which was left at the referring facility. This closes the patient's case for the referring hospital.

While this shared responsibility is apparent in the interfacility transfer of patients, it also is a factor in the prehospital transfer of patients. When a patient or family member accesses emergency medical care by the 911 system, a trained medical team will respond and transfer the patient to a hospital, if appropriate. The medical director of the emergency medical care system is responsible for the care of the patient in transport. This responsibility is shared by all individuals and facilities that support the emergency medical care system. Although this shared responsibility is subtle, it does exist in the prehospital environment.

Duty to Provide Care

Regardless of the environment, when an individual is employed and on duty, he or she has a responsibility to provide health care within the limits of their licensure. Nursing practice acts and emergency medical system guidelines outline the responsibilities of nurses, paramedics, and emergency medical care technicians. When transporting patients, these transport crew members should function within the guidelines of their state administrative codes, as well as within the protocols for care as outlined by the medical control officer.

Death of a Patient in Transport

If a patient is pronounced dead during transport, the transport crew must notify the local medical examiner in the county in which the patient died. This holds true in air transport as well if the patient's death occurs in the county over which the aircraft is flying at that time.

In everyday practice, patients are usually not pronounced dead during transport due to these legal entanglements. Many transport programs utilize nurses as the transport crew members, and, in most states, nurses are not legally allowed to pronounce a patient's death. Additionally, the transport environment does not lend itself to allowing the transport crew to make an informed decision regarding the outcome of the patient. The limited assessment tools available to the transport crew put them at a disadvantage in making an informed decision. Resuscitation efforts are usually continued until the final destination is reached and the patient can be assessed in a more sophisticated environment.

If a transport is requested for an extremely unstable patient, a decision regarding the final disposition of the patient should be made prior to departure. Patient wishes and family requests should be included in this decision-making process. If a patient experiences an arrest in transport, the team has two options: either return to the referring hospital or continue on to the receiving facility. If the transport continues on to the receiving facility and the patient expires in that hospital, the family should make arrangements to retrieve the body for burial. This is costly and often involves a large amount of paperwork.

On the other hand, the family may be in transit to the receiving facility, and if the patient is returned to the referring hospital, the family is left to wonder where their loved one is and why he or she has not yet arrived. This also creates a dilemma for the family who must return to the referring facility and who may be distraught and incapable of driving back home safely.

There is no easy answer to dealing with the death of the patient. It is a risk that is increased in transport; the transport environment puts additional stressors on the patient and patients who are transported are generally unstable to begin with. The transport team should be aware of the legal ramifications as well as the family's wishes and should try to choose a course of action that will be appropriate for all involved.

MANAGEMENT ISSUES

Additional issues facing the transport team include transport delays, traversing time zones, traversing international borders, and infection control. While these issues are not a part of everyday transports, they do arise on occasion and should be prepared for prior to departure.

Transport Delays

Transport delays can be caused by a number of factors, including weather, mechanical breakdown, fueling requirements, and missed connections. Pretrip planning should include an assessment of current and future weather conditions, yet this does not guarantee that the weather will not change for the worse during the transport itself.

Weather problems can cause the delay of the transfer, diversion of the transport to an alternate facility, or cancellation of a transport. The transport team should be alert to these possibilities and make arrangements prior to departure. Having an adequate supply of equipment on board to care for the patient during a delay is a necessity. While it would be convenient to have a large amount of IV fluids and dressings, it is neither practical nor safe (in air transport weight is an important issue). The team should always be aware of their situation and the availability of backup supplies. When it appears that the supplies are running low, an alternate plan should be instituted. The team cannot wait to make a decision after their supplies are exhausted.

Mechanical breakdowns are never intended, but do occur (e.g., a flat tire on a ground ambulance is always a possibility and should be prepared for). Mechanical breakdowns in aircraft are usually slower to be repaired; parts are not readily available and an alternative mode of transport should be sought.

Missed connections should never occur with proper pretransport planning, but nonetheless, they do happen. This is most often a problem of fixed-wing transports, when a number of crew members are involved. The aircraft should notify the ground ambulance of their estimated time of arrival so that the airplane can be met immediately upon arrival. However, if transport delays do occur, the ground ambulance may not be notified and the team has to wait at the airfield for the ambulance. It is best to assign one individual on the ground who can be notified of any delays; it is then this individual's responsibility to notify others. Many transport programs now employ a communications specialist, or transport team dispatcher, who is responsible for all communications beginning with the first call requesting transport until the transport is completed and all appropriate individuals have been notified. This individual is critical to a smooth running operation.

It is also important to keep the family informed of delays. If the family has been told that the patient will arrive in one hour, and a delay occurs causing the length of transport to increase to one and one-half hours, the family will spend the last half hour in a state of worry. Fear that an accident has occurred will escalate until the family is convinced that a catastrophe has occurred and everyone has been killed. The family is already anxious due to the nature of the transport; they do not need any additional stressors.

Whenever a transport is delayed, the team should be resourceful and, if necessary, institute an alternate plan. However, this too may have to be changed. Individuals who are obsessively tied to standing protocols and unable to deal with change should not be in the transport environment.

Traversing Time Zones

The problems encountered when traversing time zones include changes to the times of medication administration, disruption of meal times, disruption of sleep patterns, and arrival and departure after hours. When traversing only one or two time zones with only an hour or two time change, these problems are not significant. However, when transporting the patient long distances over many time zones, these issues become more important.

Times of medication administration generally remain on the schedule initiated at the referral facility. In transport, the crew can continue with this schedule to ensure that the patient is receiving the appropriate medication in a timely manner. Upon arrival at the receiving facility, these times can be adjusted to meet the needs of the patient and staff.

Disruption of meal times can be avoided when preplanning occurs. If a patient is on a set meal schedule and is scheduled to be in transport during that time, a bag lunch can be prepared for the patient. Not only is this important to consider during the transport, but the time of arrival at the receiving facility should also be considered. If arrival is after hours and no food service is available, the patient should be able to have a source of nourishment.

Disruption of the circadian rhythms is a common consequence of hospitalization. A number of research studies have shown this to be harmful for the patient; however, it is something that is often unavoidable. During transport, the patient can be allowed, and should be encouraged, to sleep. The number of interventions is limited and it is a perfect time to rest. However, the transport crew becomes concerned when the patient experiences somnolence that accompanies hypoxia. Utilizing a pulse oximeter in this situation can prevent unnecessary arousal of the patient.

After-hours arrivals and departures can also produce delays in transport. As an example, a patient arrives in the middle of the night at the receiving facility and the number of staff is inadequate to care for this additional patient, or the patient needs an x-ray, but the x-ray technician is not in-house during the night shift. All of these problems can be eliminated with pretransport planning. If the patient is to arrive in the middle of the night, the staff should be informed well ahead of time and additional staff should be awaiting the patient's arrival.

Avoiding the problems associated with transport delays is easily accomplished with preplanning. Communication between all involved parties will minimize a number of these complications, expediting the patient's arrival.

Traversing International Borders, Language, and Culture

Patients injured or taken ill while traveling abroad are those who usually require transfer across international borders; this is commonly referred to as aeromedical repatriation. This may include either individuals who are citizens of the United States. and want to return to their home facility or foreigners to the United States who are transferred to their home country. Regardless of the direction of the transport, international borders must be crossed.

Care in international transport is no different than care in other transports. The transport times may be long and the team should make arrangements for adequate supplies and equipment. Transport delays commonly occur when crossing a border, and the team should take the possible delay into consideration.

Immigration and customs requirements vary depending on the country, the citizenship of the individuals in the transport, and the country in which the transport started. In emergency situations, most immigration and customs offices are very helpful in expediting the arrival process. Early notification of these government officials will allow for arrangements to be made ahead of time. Usually these officials will be readily available when the transport arrives at the border offices so that the transport can be rapidly continued. One of the biggest concerns of these officials is the transporting of controlled substances (narcotics) over the border. Most programs that perform these transports on a regular basis have an established document citing the type and amount of narcotics on board. The officials can then quickly check these counts and clear the vehicle and crew.

Another complication that occurs with international transport is communication difficulties. The services of a translator may be required, and arrangements for these services should be made prior to departure. Additionally, the patient and his or her family may not speak English, complicating communication between the transport crew and the patient and family. Bilingual crew members are an added resource in these situations. As in any healthcare situation, cultural differences should also be considered and addressed.

Infection Control

The risk of infectious disease in the transport environment is high. The patient is at increased risk for two reasons: their disease or injury may predispose them to infection; and the transport environment is not sterile, although cleanliness is always a goal of transport crew members. The number of environmental changes that the patient experiences in transport can increase their exposure to contaminants. Ensuring that the patient is covered and protected should always be a consideration.

Crew members are also at risk. The incidence of Mycobacterium tuberculosis, HIV, and hepatitis infection has become prevalent in the prehospital environment. This, coupled with the increased number of multi-drug resistant and virulent bacterial strains, indicates a necessity for much caution. Crew members need to reduce their risk of exposure; therefore, the use of barrier protection should be instituted at all times.

During transport, there is no access to hand-washing, although alcohol-based hand sanitizers can be useful. Gloves should be utilized and changed to reduce contamination. Wrapping and sealing contaminated dressings and linen should be performed to prevent exposure to those individuals who may be assisting with cleaning the vehicle at the termination of the transport.

Recognition of potential hazards should alert the transport crew to take appropriate precautions. Once the patient arrives at their destination, the covering over the patient should be replaced to reduce bringing outside contaminants into the hospital.

FUTURE DEVELOPMENTS

As health management continues to expand and develop, more patients will require and/or desire access to new therapies. It will be necessary for those involved in transporting patients to keep abreast of these therapies in order to provide advanced care during transport. Education and training programs dealing exclusively with aspects of transport care are being developed. Case Western University offers an educational program, the Dorothy Ebersbach Academic Center for Flight Nursing, specifically for those nurses involved in patient air transport. Programs such as this are coming to the forefront of education of transport nurses. Emergency department physicians are also being trained and made more aware of the parameters associated with patient transport.

10. SUMMARY

Transporting the ill or injured patient is a challenging and exciting part of health care. Transport programs have been developed to provide patients whose medical needs surpass available resources with a variety of modes of transport, including ground and air transport. The transport environment introduces the patient to a number of stressors, which can occur in all modes of transport.

Transport regulations ensure that all patients who are in need of transport are transported in a safe and timely manner. The legal steps in arranging a transport are well delineated, and it is every individual's responsibility in caring for the patient to ensure that these steps are met.

Patients need to be stabilized appropriately to limit the stressors occurring in the transport environment. Stabilization of the airway, ventilatory system, and circulatory system is crucial prior to moving a patient from one locale to another. Additional stabilization measures should be undertaken depending on the patient's problems and condition at the time of transport. Each individual patient should be evaluated for the effects of the stressors of transport and stabilized appropriately.

Transporting patients is recognized as an integral part of their care; guarding their safety should be foremost in each individual's mind. The medical-legal aspects of transport should be met, ensuring that professional standards are maintained.

Only a small population of healthcare providers are actually involved in transporting patients, but all individuals caring for patients who are to be transported, or who have been transported, should be aware of these principles of care in transport.

11. INTERNET RESOURCES

Many organizations and associations offer additional information regarding emergency medical transport. A list of organizations and their Web sites is provided here as a resource, to allow for further research.

Air and Surface Transport Nurses Association (ASTNA)

https://www.astna.org

American Academy of Pediatrics Section on Transport Medicine

https://www.aap.org/en-us/about-the-aap/Sections/Section-on-Transport-Medicine/Pages/SOTM.aspx

Association of Air Medical Services

https://www.aams.org

Commission on Accreditation of Medical Transport Systems

https://www.camts.org

CONCERN Network

http://www.concern-network.org

International Academy of Aviation and Space Medicine

https://www.iaasm.org

MedEvac Foundation International

http://medevacfoundation.org

National EMS Pilots Association (NEMSPA)

http://www.nemspa.org

The Dorothy Ebersbach Academic Center for Flight Nursing, Case Western Reserve University

https://case.edu/nursing/research/centers-of-excellence/the-dorothy-ebersbach-academic-center-for-flight-nursing

Works Cited

1. Wilson WC, Grande CM, Hoyt DB (eds). Trauma: Emergency Resuscitation Perioperative Anesthesia Surgical Management. Vol 1. New York, NY: Informa Healthcare USA; 2007.

2. Pittman RN. Regulation of Tissue Oxygenation. San Rafael, CA: Morgan and Claypool Life Sciences; 2011.

3. Federal Aviation Administration. Federal Aviation Regulations: Part 91.211. Available at http://rgl.faa.gov/Regulatory_and_Guidance_Library/rgFAR.nsf/0/ba9afbf96dbc56f0852566cf006798f9!OpenDocument#_Section1. Last accessed June 4, 2019.

4. Pretorius T, Bristow GK, Steinman AM, Giesbrecht GG. Thermal effects of whole head submersion in cold water on nonshivering humans. J Appl Physiol. 2006;101(2):669-675.

5. Insoft RM, Schwartz HP (eds). Guidelines for Air and Ground Transport of Neonatal and Pediatric Patients. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2015.

6. Wilkinson F. Nepal's High-Risk Helicopter Rescue Unit. Available at https://www.mensjournal.com/adventure/nepals-high-risk-helicopter-rescue-unit-20150113. Last accessed June 2, 2019.

7. Ergan B, Akgun M, Pacilli AMG, Nava S. Should I stay or should I go? COPD and air travel. Eur Respir Rev. 2018;27(148).

8. Bradi AC, Faughnan ME, Stanbrook MB, Deschenes-Leek E, Chapman KR. Predicting the need for supplemental oxygen during airline flight in patients with chronic pulmonary disease: a comparison of predictive equations and altitude simulation. Can Respir J. 2009;16(4):119-124.

9. Brain Trauma Foundation. Guidelines for the management of severe traumatic brain injury; 4th edition. J Neurotrauma. 2017;80(1):1-244.

10. Warren J, Fromm RE Jr, Orr RA, Rotello LC, Horst HM. Guidelines for the inter- and intrahospital transport of critically ill patients. Crit Care Med. 2004;32(1):256-262.

11. American College of Surgeons Committee on Trauma. Resources for Optimal Care for the Injured Patient: 2014. Chicago, IL: American College of Surgeons; 2014.

12. U.S. Department of Health and Human Services. Burn Triage and Treatment: Thermal Injuries. Available at https://chemm.nlm.nih.gov/burns.htm. Last accessed June 4, 2019.

13. Blumetti J, Hunt JL, Arnoldo BD, Parks JK, Purdue GF. The Parkland formula under fire: is the criticism justified? J Burn Care Res. 2008;29(1):180-186.

14. Centers for Disease Control and Prevention. Emergency Medical Services Workers: Injury Data, 2016. Available at https://www.cdc.gov/niosh/topics/ems/data.html. Last accessed June 4, 2019.

15. U.S. Department of Transportation, National Highway Traffic Safety Administration. Feasibility for an EMS Workforce Safety and Health Surveillance System. Bedford, MA: Bedford Research; 2007.

16. Commission on Accreditation of Medical Transport Systems. Accredited Services. Available at https://www.camts.org/services. Last accessed June 2, 2019.

17. Centers for Medicare and Medicaid Services. Emergency Triage, Treat, and Transport (ET3) Model. Available at https://innovation.cms.gov/initiatives/et3/. Last accessed June 5, 2019.

Works Consulted

1. Moyle J. Medical guidelines for airline travel. Aviat Space Environ Med. 2003;74(5 suppl):A1-A19.

2. Blumen IJ, Rinnert KJ. Altitude physiology and the stresses of flight. Air Med J. 1995;14(2):87-100.

3. Brown J, Tompkins K, Chaney E, Donovan R. Family member ride-alongs during interfacility transport. Air Med J. 1998;17(4):169-173.

4. Commission on Accreditation of Medical Transport Systems. 11th Edition Accreditation Standards. Available https://www.camts.org/wp-content/uploads/2017/05/CAMTS-11th-Standards-DIGITAL-FREE.pdf. Last accessed June 5, 2019.

5. Davis DP, Peay J, Serrano JA, et al. The impact of aeromedical response to patients with moderate to severe traumatic brain injury.Ann Emerg Med. 2005;46(2):115-122.

6. Emergency Medical Treatment and Active Labor Act (EMTALA), USC §1867 (1986).

7. Rainford DJ, Gradwell DP (eds). Aviation Medicine. 4th ed. London: Hodder Arnold; 2006.

8. Essebag V, Halabi AR, Churchill-Smith M, Lutchmedial S. Air medical transport of cardiac patients. Chest. 2003;124(5):1937-1945.

Evidence-Based Practice Recommendations Citations

1. Theodore N, Hadley MN, Aarabi B, et al. Prehospital cervical spinal immobilization after trauma. In: Guidelines for the management of acute cervical spine and spinal cord injuries. Neurosurgery. 2013;72(Suppl 2):22-34. Available at https://www.cns.org/sites/default/files/guideline-chapter-pdf/Prehospital_Cervical_Spinal_Immobilization_After.6.pdf. Last accessed July 8, 2019.

2. Mayglothling J, Duane TM, Gibbs M, et al. Emergency tracheal intubation immediately following traumatic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S333-S340. Available at https://www.east.org/education/practice-management-guidelines/endotracheal-intubation-following-trauma. Last accessed July 8, 2019.

3. Theodore N, Aarabi B, Dhall SS, et al. Transportation of patients with acute traumatic cervical spine injuries. In: Guidelines for the management of acute cervical spine and spinal cord injuries. Neurosurgery. 2013;72(Suppl 2):35-39. Available at https://www.cns.org/sites/default/files/guideline-chapter-pdf/Transportation_of_Patients_With_Acute_Traumatic.7.pdf. Last accessed July 8, 2019.

4. Sasser SM, Hunt RC, Faul M, et al. Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage, 2011. MMWR. 2012;61(RR1):1-20. Available at https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6101a1.htm. Last accessed July 8, 2019.

30763 • Postoperative Complications

Susan Engman Lazear, RN, MN

www.netce.com

Copyright © 2021 NetCE, All rights reserved.

Postoperative complications are a constant threat to the millions of people undergoing surgical interventions. Whether patients are managed in a hospital setting, an ambulatory care facility, or in a free-standing operating suite, the development of postoperative complications can lead to long-term disability and possibly death. Complications will be discussed utilizing an easy-to-decipher approach, beginning with detection and ending with appropriate steps to treat and/or reverse these untoward events. The underlying physiology will be presented to allow the reader to determine which patients would be at high risk for these developments. In addition, postoperative complications that are common to pediatric, geriatric, and obese patient populations will be addressed.

Table of Contents

30763 • Postoperative Complications

Course Overview

Audience

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planner

Division Planner Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. ASSESSMENT OF THE POSTSURGICAL PATIENT

CARDIOVASCULAR SURGERY

ABDOMINAL SURGERY

ORTHOPEDIC SURGERY

RESPIRATORY TRACT SURGERY

NEUROSURGERY

OBSTETRIC/GYNECOLOGIC SURGERY

GENITOURINARY SURGERY

OPHTHALMOLOGIC SURGERY

ORAL AND FACIAL SURGERIES

CASE STUDY

3. GLOBAL COMPLICATIONS

POSTOPERATIVE NAUSEA AND VOMITING

MALIGNANT HYPERTHERMIA

POSTOPERATIVE HYPOTHERMIA

POSTOPERATIVE PAIN

COMPLICATIONS OF SURGICAL POSITIONING

4. COMPLICATIONS WITHIN BODY SYSTEMS

PULMONARY COMPLICATIONS

CARDIOVASCULAR COMPLICATIONS

NEUROLOGIC COMPLICATIONS

VOLUME STATUS COMPLICATIONS

GASTROINTESTINAL AND GENITOURINARY COMPLICATIONS

5. COMPLICATIONS IN SPECIFIC PATIENT POPULATIONS

PEDIATRIC PATIENTS

GERIATRIC PATIENTS

MORBIDLY OBESE PATIENTS

6. CONCLUSION

7. GLOSSARY OF TERMS

Works Cited

Evidence-Based Practice Recommendations Citations

30763 • Postoperative Complications

Education Category. Medical / Surgical

Release Date. 02/01/2021

Expiration Date. 01/31/2024

Course Overview

Postoperative complications are a constant threat to the millions of people undergoing surgical interventions. Whether patients are managed in a hospital setting, an ambulatory care facility, or in a free-standing operating suite, the development of postoperative complications can lead to long-term disability and possibly death. Complications will be discussed utilizing an easy-to-decipher approach, beginning with detection and ending with appropriate steps to treat and/or reverse these untoward events. The underlying physiology will be presented to allow the reader to determine which patients would be at high risk for these developments. In addition, postoperative complications that are common to pediatric, geriatric, and obese patient populations will be addressed.

Audience

This course is designed for all nurses and allied professionals involved in the care of patients who undergo surgical procedures, especially those who work in the preoperative area, the operating room, or the postanesthesia unit in hospitals or free-standing surgical centers.

Course Objective

The purpose of this course is to provide nurses and all allied health professionals who care for postsurgical patients the knowledge necessary to recognize and manage common postoperative complications, improving patient care and outcomes.

Learning Objectives

Upon completion of this course, you should be able to:

1. List the steps necessary to obtain an accurate and thorough assessment of patients prior to, during, and after surgery.

2. Identify information that should always be obtained during the assessment of the preoperative patient.

3. Review the common complications of patients undergoing abdominal, orthopedic, cardiovascular, respiratory, neurologic, obstetric/gynecologic, and genitourinary surgeries.

4. Describe the development, course, and management of postoperative nausea and vomiting (PONV).

5. Discuss the signs and symptoms as well as the treatment of malignant hyperthermia.

6. Review the implications of hypothermia, pain, and complications related to positioning in postsurgical patients.

7. List the most common respiratory complications following surgery and how to best identify and manage these complications in the postanesthesia care unit (PACU).

8. Describe the cardiovascular complications that may occur in the postoperative period and the appropriate interventions.

9. Discuss the development and management of postoperative neurologic complications.

10. List the steps to appropriately assess and manage the patient with a volume status complication in the postoperative period.

11. Outline the steps to managing postoperative ileus.

12. Identify the signs/symptoms, risk factors, and management of postsurgical renal insufficiency.

13. Describe the anatomic and physiologic differences between children and adults and how these differences impact postoperative care and complication development.

14. Identify the anatomic and physiologic differences between elderly and adult patients and the impact that these differences have on the development of postoperative complications.

15. Develop a plan for assessment and management to be instituted in the PACU to limit the development of postoperative complications in the morbidly obese patient.

Faculty

Susan Engman Lazear, RN, MN, received her undergraduate education at the Walter Reed Army Institute of Nursing in Washington, D.C. After completing her BSN, she served as an Army Nurse at Letterman Army Medical Center in San Francisco for four years. She then attended the University of Washington School of Nursing and received a Master’s in Nursing, specializing in Burn, Trauma and Emergency Nursing. After receiving her MN, she started Airlift Northwest, the air ambulance service based in Seattle which serves the entire Northwest region, including Alaska. Mrs. Lazear left the air ambulance service to start her own nursing education and consulting business, Specialists in Medical Education. For the past 20 years she has been teaching emergency nursing courses throughout the country. She lives in the Seattle area. Mrs. Lazear continues to teach and publish. She is both an editor and contributing author of Critical Care Nursing, published by W.B. Saunders Company, in June of 1992. She served as an author and reviewer of the Emergency Nursing Core Curriculum 6th Edition, published by W.B. Saunders Company in 2007. She has been named to the Who’s Who in American Healthcare list annually since 1992.

Faculty Disclosure

Contributing faculty, Susan Engman Lazear, RN, MN, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planner

Jane C. Norman, RN, MSN, CNE, PhD

Division Planner Disclosure

The division planner has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

Postoperative complications are a constant threat to the millions of people undergoing surgical interventions. Whether patients are managed in a hospital setting, an ambulatory care facility, or in a free-standing operating suite, the development of postoperative complications can lead to long-term disability and possibly death. Healthcare professionals caring for patients during the postoperative period should be alert to complication risks and institute measures for risk reduction.

Hospital discharge statistics demonstrate changes in hospitalization and trends. While many patients are being treated in the outpatient setting, the elderly population is increasingly using inpatient resources [1]. With the advent of new technology, new medications, and minimally invasive procedures, the frequency of surgical operations continues to increase. The procedure with one of the greatest increases in frequency is knee replacements. In 2014, the American Academy of Orthopaedic Surgeons (AAOS) reported that the rate of knee replacements for patients between 45 and 64 years of age increased by 188% between 2000 and 2009 [2]. Among this age group, this trend is projected will continue, with an increase of 149% of total knee replacements between 2020 and 2040 [92]. While knee replacements were originally considered an elderly person's procedure, younger patients have chosen to have the procedure done to enhance their lifestyle. Patients are no longer willing to live with pain and disability when the problem can be fixed. However, with this increase in procedures comes an increase in complications. One of the greatest risks for the knee replacement patient is the development of a deep vein thrombosis (DVT). The good news is that it is possible to anticipate who is at risk and institute risk reduction measures earlier in the course of care.

In 2010, approximately 35.1 million inpatients were discharged from short-stay hospitals [3]. The patients varied in age from infants to adults older than 100 years of age, with 51.4 million procedures performed [3]. In 2010, procedures on the cardiovascular system were common, with 2.7 million procedures performed. Procedure rates varied by sex; men were more likely to have a cardiovascular procedure, while women were more likely to have an operation on the digestive system [4]. Approximately 43% of all procedures performed on women were obstetrical in nature [4].

Management of postoperative complications requires astute assessment throughout the operative cycle. Preoperative assessment is critical to ascertain which patients are at risk for complication development. Preoperative personnel should evaluate each patient for their medical history, medication use, physical limitations or disabilities, previous surgical and/or anesthesia history, and psychosocial and emotional status. Operating room personnel should be vigilant for those factors that increase the risk for postoperative complications, including positioning of the patient, the temperature of the operating suite and equipment used, and the length of the surgical intervention. Certain measures can be instituted while the patient is under anesthesia to prevent complication development in the postoperative phase of care.

The staff caring for the patient in the postoperative environment may have the greatest impact on preventing complication development. Awareness of complication development is the first step in risk reduction. Complications can occur at various periods in the recovery phase. Risk of developing hypotension, myocardial infarction, and respiratory depression is greatest in the first postoperative day. Between days 1 and 3, the risk of congestive heart failure, pulmonary embolus, and respiratory failure increases. Pneumonia generally occurs between days 4 and 7, while cerebrovascular accident and sepsis occur most commonly between 8 and 30 days postoperatively. Other complications, such as cardiac arrhythmias and gastrointestinal (GI) tract bleeding, occur throughout the postoperative period at an equal rate [5].

Postoperative personnel should review the history and physical status of the patient as well as the operative report to identify risk factors. If noted, measures should be instituted to reduce the risk. Identification of at-risk patients is the key to successful risk reduction. This course will provide necessary information in a straightforward approach. Patient assessment will be presented in a logical, step-by-step format. Complications of the major body systems will be discussed, focusing on symptom recognition and risk reduction measures. Finally, a review of postoperative complications in pediatric, elderly, and morbidly obese patients will be offered. It is imperative that any healthcare professional caring for the postoperative patient, whether in the phase I postanesthesia care unit (PACU) or the surgical unit, be aware of these risks. With successful reduction and early recognition of these complications, the patient's risk of life-long disability and/or death will be greatly diminished.

2. ASSESSMENT OF THE POSTSURGICAL PATIENT

Reducing the risk of postoperative complications can be accomplished with a thorough assessment of the patient upon arrival in the PACU. Risk reduction measures should be instituted early on in the course of care to decrease the incidence of complicating factors that can lead to prolonged disability and even death. Awareness of patients who are at risk can alert staff to potential complications. Many of these complications are addressed in detail throughout the remainder of this course and will be introduced here.

A systems assessment should be completed within the first few minutes of arrival in the PACU. A report should be received from the operating room personnel accompanying the patient to the PACU. With this information in mind, a plan of care can be developed to ensure the safety and rapid recovery of the postsurgical patient. Reassessment should be performed on a regular, ongoing basis to ensure that changes in patient condition are recognized and treated early. Readiness for discharge is based upon the patient's status, which should be consistent with the baseline values identified in the preoperative phase of care.

Airway, breathing, and circulatory responses (ABCs) are the first parameters to be assessed. Patients may be admitted to the PACU with an endotracheal tube in place to ensure airway patency. While the patient is transferred from the transport gurney to the PACU bed, this tube may become dislodged; it is imperative that tube patency and location are checked immediately upon admission. Other patients will be admitted to the PACU without an airway device in place; these patients should be positioned to prevent aspiration, and airway patency should be assessed until the full return of protective reflexes.

Breathing adequacy should be assessed, breath sounds should be auscultated, and oxygen saturations should be monitored continuously. Hypoxemia is one of the most common complications to develop in the postoperative phase of care, and patients at risk can be identified at this early juncture. Patients who received neuromuscular-blocking agents (i.e., paralytic agents) in the operating room are at risk for weak ventilatory effort and the loss of respiratory drive. Assessing patients' return to function can be performed with a nerve stimulator device, if necessary. Supplemental oxygen may be used in the early phase of care to ensure adequate gas exchange.

Postoperative circulatory status should be identified upon admission. Volume depletion or volume overload should be treated early to prevent stressors upon the cardiovascular system. Volume replacement should be continued, if ordered, and signs of volume status, including urine output measurements, should be performed. Peripheral tissue perfusion should be evaluated; signs of impending circulatory compromise should be identified and managed early to prevent tissue destruction. Cardiac monitoring should be performed to identify patients at risk for cardiac conduction disturbances, including dysrhythmia formation.

Vital sign assessment is performed on a regular basis. Initial admission vital signs may not be consistent with those obtained in the preoperative phase of care. Inhalation anesthetics have vasodilator capabilities, and it is common for the patient to be initially hypotensive in the recovery phase. Anticholinergic medications, such as atropine, may have been administered; if so, the patient will exhibit an increased heart rate. Respiratory effort may be weak due to residual muscular blockade, and oxygen saturations may be altered secondary to a number of factors, including hypothermia and hypoxemia. Over the course of care in the PACU, vital signs should normalize and be consistent with those obtained prior to surgery. However, this generalization should be tempered with the statement that not all vital signs obtained prior to surgery are "normal." A patient who is anxious in the preoperative phase of care may have an abnormally high blood pressure and pulse rate, and the vital signs obtained in the PACU may be more consistent with the true "normals" of the patient.

Postoperative neurologic status is also important to assess, recognizing that the patient will continue to fluctuate from an alert status to a somnolent state. Over the course of care, the patient should begin to awaken and remain lucid. Initially, the patient will not be oriented and will need reminders as to place and time. The risk of emergence delirium is higher in pediatric patients and should always be considered when managing young children. Children may awaken in a state of fear and become combative, increasing the risk of harming themselves. Ensuring a safe recovery environment is critical to preventing these complications. Elderly patients may experience a delayed awakening state, which can be caused by many factors.

Rarely do patients awaken from general anesthesia with a loss of motor or sensory function, although these functions should be assessed. Patients who undergo local or regional anesthesia should be evaluated for return of sensory and motor control as well. Monitoring return of function with a dermatome chart will allow for recognition of full function.

Assessing pain, which is considered the "fifth vital sign," should be performed as soon as the patient is stabilized in the PACU. Pain location, intensity, duration, and quality should be evaluated. Treatment of pain should not be delayed due to concerns over vital signs. Using a multimodal approach to treatment will ensure that the patient receives a variety of measures to assist with pain control. Pain management should be reassessed on a frequent basis, and new or changed reports of pain should be evaluated and treated.

Wound and skin assessment should be performed, including assessment of the surgical site. Skin integrity should be evaluated at the surgical site as well as any areas that were prone to pressure while under anesthesia. Positioning of patients in the operating room can put increased stressors on skin, and pressure areas should be identified in the recovery period. Ensuring proper position in the recovery area can reduce the risk of further complications.

Core body temperature readings should be attained. Hypothermia is common in the postoperative phase and can complicate healing and return to a normal state. Obtaining core temperatures using infrared tympanic monitors and temporal thermometry has been recommended as the preferred routes of temperature measurement in this setting [6]. It is important to recognize that accuracy will vary depending on the site, the device used, and the patient's condition. Patients should be assessed for chills and shivering as signs of hypothermia. Forced warm air devices may be used to assist in raising the core temperature of those patients who are hypothermic in the recovery area.

Complaint of nausea and vomiting is frequent in the recovery phase. It is important to determine which medications, if any, were administered in the operative phase of care to manage postoperative nausea and vomiting (PONV). If a class of drugs is not working and the patient continues with complaints of nausea, the recommendation is to switch to another class. Vomiting is not common; however, should it occur, there are multiple risks to the patient.

The GI and genitourinary (GU) systems require assessment. The shape and size of the abdomen should be noted, and any alteration should be re-evaluated every 15 to 30 minutes. Patients with abdominal drains and/or Foley catheters should have output measured regularly. These patients have an increased risk of DVT development and should be positioned to reduce this risk.

Medication administration should be considered. Intravenous sites should be assessed for patency, as catheters commonly remain in place until the time of discharge. Antibiotic therapy may be initiated in the PACU. If this is the case, the patient should be evaluated for any signs of developing allergic response, including hives and swelling of the face and mouth. Timing of follow-up medications should be identified and charted to ensure a smooth continuum of care.

Patients often leave the operating room with many drains and tubes. These devices should be checked for proper functioning and the sites documented. Nasogastric, urinary, and chest drainage should be collected, measured, and noted on the intake/output record. Blood collection drains should be monitored; subsequent fluid intake is often calculated on these losses. Continual assessment should be performed to ensure that the tubes and drains are not occluded or kinked, preventing their normal functions.

Fluid and electrolyte status should be assessed when time permits. Blood loss, third spacing of fluids (i.e., when fluid is lost to the surrounding tissues), and the NPO status of the patient can all impact fluid balance in the recovery phase. Electrolyte measurement should be undertaken as ordered. Monitoring the cardiac conduction system via electrocardiograph (ECG) will allow for recognition of possible life-threatening dysrhythmia formation secondary to electrolyte imbalance.

The emotional state of the patient should be included in the postsurgical assessment. Surgical interventions cause anxiety for many, and upon awakening, patients may be concerned about the outcome of the surgery. Children will benefit from a parent's presence, which helps to ease the fear of the unknown. Spouses or significant others may be allowed to visit when the patient's condition warrants these visits.

Many PACUs use scoring systems for evaluation of the patient's readiness for discharge. These scoring systems allow the staff to follow the patient's recovery and calculate a score documenting their improvement. The scores that assess for consciousness, breathing, oxygenation, circulation, and movement are the most commonly used in determining readiness for discharge. If scores are obtained upon admission, then on a repeat basis, the patient will demonstrate improvement in these vital parameters. When complications arise, they may be evidenced in either a decreasing score or a lack of improvement in the score.

CARDIOVASCULAR SURGERY

Each patient population is at risk for specific postoperative complications. As the population ages and technology advances, the ability to correct and repair cardiac disturbances is becoming more common across the life span. Patients undergoing cardiovascular procedures require constant cardiac monitoring during the first few days postoperatively. These patients are at heightened risk for dysrhythmias and hypoxic events. Often, indwelling catheters will remain in place for measurement of cardiac pressures and function. Alterations in cardiac function should be immediately reported to the surgeon and cardiologists in charge of the patient's recovery.

The stressors of surgery place a huge strain upon the heart, and compensatory mechanisms are limited. Alteration in medication administration to support cardiac function is performed to support the injured myocardium. Heart surgery patients may also experience a significant amount of pain when an open procedure is performed. Less invasive procedures are being performed more frequently, but open-heart procedures are still numerous. The disruption of the integrity of the chest cavity is very painful, and good pain management is critical to ensure that the patient cooperates with the postoperative exercises that are required to speed recovery. Ventilatory effort should be assessed on a regular basis to ensure that patients are able to clear secretions, preventing the development of pneumonia. As for all patients, assessment of all body systems should be undertaken to make certain that no other issues or complications go undetected.

ABDOMINAL SURGERY

Abdominal surgeries may be performed using a variety of approaches, including laparoscopy. Patients who undergo these procedures should be instructed to support their abdomen and surgical site when coughing or moving to reduce stress upon the incision site. The size and shape of the abdomen should be monitored, and any change should be immediately reported to the surgeon. Accurate intake and output measurements should be maintained, including the volume of fluid lost through drains. If possible, nausea and vomiting should be controlled, as retching will put stress on the surgical site. Patients undergoing stoma formation should be assessed for color and condition of the new stoma. These patients are at risk for fluid and electrolyte imbalances, especially hypovolemia, and assessment and replacement should be continued in the recovery period. Due to the length and extent of the procedures, abdominal surgery patients are commonly hypothermic upon return to the PACU. Patients undergoing abdominal procedures are at increased risk for DVT, paralytic ileus, infection, and wound dehiscence [7,8]. In addition, laparoscopic abdominal procedures may result in shoulder pain due to gas inflation of the abdomen.

ORTHOPEDIC SURGERY

Fracture repairs, total hip and/or knee replacements, and amputations are a few of the commonly performed orthopedic procedures. Slightly more women than men have these procedures; it is postulated that the bone loss that occurs in postmenopausal women puts them at increased risk of injury requiring surgical repair [9]. Patients who have orthopedic procedures require accurate assessment of their neurovascular status, including color, pulses, temperature, capillary refill, sensation, and movement of the affected area. Body alignment should be maintained, as ordered. Supplemental traction devices, casts, or braces should be assessed for pressure areas. Edema is common, and elevation of the affected limb can reduce this risk. DVT risk is higher in this group of patients than any other patient population [10,11]. Therefore, recommendations for DVT prophylaxis should be closely adhered to. Compartment syndrome may develop. The patient may be at risk for osteomyelitis, and hypovolemia is common in the postoperative phase. Patients undergoing amputation require close monitoring of their distal perfusion.

RESPIRATORY TRACT SURGERY

Surgery on the respiratory tree carries a high risk of postoperative hypoxia and respiratory compromise. The goals of postoperative care in these patients include optimization of respiratory function, liquefaction and mobilization of secretions, and re-expansion of the lungs. Patients will be admitted to the PACU with one or more chest tubes in place. It is critical that the integrity of these tubes be maintained to allow for drainage and reinflation of the lung. Thoracic procedures may be accompanied by a significant blood loss intraoperatively; therefore, volume assessment and the infusion of fluids and blood products should be continued in the PACU. Many of these patients are admitted with an endotracheal tube in place and require mechanical ventilatory support. Patients should receive supplemental oxygen and humidification to prevent accumulation of secretions in the respiratory tract. Pain is a significant issue, and management of pain should be instituted with consideration of the effects of narcotics on the respiratory drive. As soon as tolerated, chest physiotherapy can be initiated to prevent and/or treat atelectasis. Postoperative pneumonia is common; prophylactic antibiotics are ordered to reduce this risk.

NEUROSURGERY

Neurosurgeries require extensive training and care during the operative and postoperative phases. For this reason, many centers do not perform these types of interventions. Rather, there are specialized care facilities at centers throughout the country to perform neurosurgeries. In the recovery period, these patients require astute, frequent assessment of their neurovascular status. The patient's status often improves as the patient is rewarmed and electrolyte imbalances are corrected. Rises in intracranial pressure (ICP) should be prevented, if possible. Proper positioning is important to ensure drainage from the cranial vault. In addition, the patient should be instructed to limit activities that increase ICP, including coughing and straining. Good pulmonary hygiene is important to prevent respiratory infection and limit rises in ICP. Complications following neurosurgical interventions include postoperative hypertension, shivering, seizures, and changes in cerebral blood flow, all of which can be harmful to successful patient outcomes. Metabolic disorders can develop postoperatively, including diabetes insipidus, which, if not treated, causes a significantly dehydrated state leading to poor cerebral perfusion. Preventing further neurologic deterioration is critical to optimum care of the patient undergoing a neurosurgical procedure.

OBSTETRIC/GYNECOLOGIC SURGERY

The most common procedure performed in female patients is a cesarean delivery [4,12]. Obstetric and gynecologic surgeries include not only deliveries but hysterectomies, fibroid removal, and dilatation and curettage, among others. The use of the laparoscopic approach when possible has increased tremendously in this patient population, and this has reduced the risk of certain complications in the postanesthesia period. Pain and psychologic support may be a significant part of the postanesthesia care of these patients. Complications include disseminated intravascular coagulation (DIC), postpartum hemorrhage, and hypovolemia due to blood loss. Monitoring patients' cardiovascular status in the first few hours post-surgery is essential.

GENITOURINARY SURGERY

The most commonly performed GU procedures include correction of problems of voiding, repair of congenital defects, and prostate surgery. Included in this group of patients are those undergoing interventions to repair or correct problems of the renal system. Many of these surgical interventions are lengthy, and pressure area development is common not only due to the length of surgery but also the position of the patient while under anesthesia. Accurate intake and output are critical to ensure fluid homeostasis. Drainage systems can become blocked by clots, and the tubes should be monitored to ensure that they remain patent. Transurethral resection of the prostate (TURP) syndrome, whereby the patient develops a fluid overload state secondary to absorption of the irrigating fluid, can develop in male patients undergoing a transurethral removal of the prostate. This leads to a vascular overload, causing pulmonary and cerebral edema. Postoperative management of patients' fluid and electrolyte status is critical to successful outcomes.

OPHTHALMOLOGIC SURGERY

Patients having undergone an ophthalmologic procedure require special assistance in the recovery period. These patients may return to the PACU with eye patches over one or both eyes, which limit their ability to orient themselves to time or place. Ophthalmologic patients generally have a significant amount of pain that must be managed. Controlling rises in intraocular pressure (IOP) should be considered; vomiting, coughing, performance of the Valsalva maneuver, and pain lead to IOP rise and subsequent wound dehiscence. Signs of increasing IOP include pain around the orbit, blurry vision, changes in visual fields, and nausea. Osmotic diuretics are used to help manage rises in IOP.

ORAL AND FACIAL SURGERIES

Oral, maxillofacial, neck, and ear, nose, and throat (ENT) procedures put patients at increased risk of airway loss after surgery. Swelling and edema formation can cause pressure on the trachea and the carotid arteries. Ice packs may be applied to reduce swelling, and humidification is used to decrease bronchial constriction. When the oral cavity is involved, it is not uncommon for salivary flow to increase; this requires the use of suction to ensure the airway does not become blocked and the use of volume replacement fluids to prevent hypovolemia. A transient bacteremia can develop, leading to temperatures of 39°C to 39.5°C. Antibiotics are often administered to prevent further system sepsis from developing. Other complications that may develop in the recovery phase of care include a pneumothorax or air embolus, which may begin to develop in the operating suite.

The management of the postoperative patient includes not only a good assessment and history but recognition and awareness of potential complications that can develop in the PACU. If the staff can "prepare for the worst," (including ready access to a tracheotomy set and supplies) then management of the patient will progress smoothly without unrecognized obstacles to safe care.

CASE STUDY

Patient A is a man 37 years of age who arrives in the PACU following surgical removal of his gallbladder. Surgical intervention using the laparoscopic approach is successful.

Patient A's airway and ability to maintain respiratory stability is evaluated immediately. His respiration is 16 breaths per minute, and his heart rate is 78 beats per minute. Oxygen is being administered at 2 liters via nasal cannula. A pulse oximeter is placed on his left forefinger, and his oxygen saturation is measured at 95%. The patient is arousable but easily drifts off to sleep.

The report is received from the operating room staff. His operative course was unremarkable. Patient history obtained during the preoperative phase of care showed that he was a 2 pack per day smoker and he denies taking any prescribed or over-the-counter medications. Patient A's weight is documented at 110 kg.

Further assessment of the patient demonstrates normal skin perfusion with good capillary refill in all extremities. He has a drain in his abdomen with a small amount of yellowish discharge. The wound site and sutures are clean and dry without bleeding or discharge. No Foley catheter is in place; when questioned, he denies the need to void. Completing a head-to-toe assessment shows no other alterations from baseline.

Patient A wakes when the second set of vital signs is obtained. He reports that his pain is 6 on a 10-point scale. He states that he has pain in his shoulder and pressure in his abdomen. Morphine (5 mg) is ordered for the pain, and 4 mg is administered IV. His wife is in the waiting room, and she comes into the unit to visit and sits by his bed reading while the patient dozes off.

Repeat vital signs are obtained every 15 minutes for the first hour. At 45 minutes after admission, the patient's oxygen saturation is noted to be 90%. PACU staff suctions secretions from the patient's throat, and he is instructed on how to use the incentive spirometer. His oxygen flow is increased to 4 liters/minute by nasal cannula. No change in the patient's oxygen saturation is noted over the next 15 minutes despite compliance with the respiratory exercises.

At one hour after admission, the patient's oxygen saturations remain at 89% to 90%, his respiratory rate is 16 breaths per minute, and he is more difficult to arouse. The nurse notifies the physician of the changes in Patient A's status. Oxygen delivery is changed again to a face mask at 4 liters/minute without improvement in the oxygen saturation level. All other parameters remain stable, demonstrating a readiness for discharge.

Despite the improvement in the patient's status, the oxygenation issue remains worrisome. The patient is admitted for an overnight hospital stay, and respiratory exercises are continued, eventually demonstrating an improvement in oxygen saturations to a high of 94%. The next morning, the patient is discharged to home.

Case Study Discussion

The assessment of Patient A was thorough and well organized. The ABCs were evaluated upon admission to ensure stability of the patient. The history was ascertained, and vital signs were obtained on the recommended basis. However, despite this excellent care, the patient did not demonstrate adequate improvement in his status to be discharged the same day.

The patient's history of smoking may be the cause of the respiratory insufficiency. Whether the patient was honest in his assessment of his smoking habit could be debated; many patients do not fully and honestly report their cigarette and/or drug and alcohol use. In addition, the patient may not have reported the feelings of nasal congestion and signs of a developing "cold" to the anesthesiologist prior to surgery. Had this been shared, the surgery may have been postponed. The patient may have been instructed to cut back on cigarette use and wait until the cold symptoms subsided prior to having surgery. When patients underreport or are dishonest during the preoperative phase of care, the staff caring for the patient in the postoperative phase is put at a disadvantage.

3. GLOBAL COMPLICATIONS

POSTOPERATIVE NAUSEA AND VOMITING

PONV is a global problem affecting patients across the surgical span. This condition is generally characterized by nausea and vomiting that occurs within the first 24 hours after surgery [13]. Early PONV has an onset within the first two to six hours after surgery, commonly in the phase I PACU. Late PONV occurs within 6 to 24 hours, often when the patient has been discharged or transferred from the recovery unit. Delayed PONV occurs more than 24 hours after surgery. The term postdischarge nausea and vomiting has been used to describe the onset of nausea and vomiting after discharge from the healthcare facility. No patient is immune to the development of PONV; it is reported that one-third of patients undergoing a surgical procedure will experience PONV. In high-risk patients the risk is estimated to be as high as 70% to 80% [13,14]. It is critical for those managing postoperative patients to be aware of the triggers, methods for risk reduction, and management of this prevalent complication. PONV is the leading cause of unanticipated admission after planned ambulatory surgery [13]. The financial impact of prolonged care is estimated at millions of dollars per year.

Management of PONV begins in the preoperative phase with the recognition of at-risk patients. PONV is most common in female non-smokers with a history of PONV and/or motion sickness [14]. Risk factors can be divided into three categories: those that occur preoperatively, those that are initiated during surgery and while undergoing anesthesia, and those that occur postoperatively (Table 1). A Simplified Risk Factor Identification Tool can be used to judge the level of risk from low to very severe (Table 2). It is important to note that the risk of developing PONV increases with the number of risk factors (Table 3). Recognition of patients at risk for PONV should be relayed to anesthesia providers so they may institute prophylactic measures while the patient is still under the effects of anesthesia.

Table 1: RISK FACTORS FOR THE DEVELOPMENT OF POSTOPERATIVE NAUSEA AND VOMITING

Patient Characteristic

Risk Factor

Preoperative Risks

Age

School-age children

Sex

Female

Past medical history

History of previous PONV

History of motion sickness

Preoperative assessment

Obesity

History of delayed gastric emptying disorders

Premedications

Opioids

Other

Anxiety

Nonsmokers

Intraoperative Risks

Surgery type

Abdominal procedures

Gynecologic procedures

Orchidopexy

ENT procedures

Strabismus repairs

Craniofacial surgery

Duration of surgery

Lengthy (longer than 60 minutes)

Anesthetic drugs

Inhalation agents

Nitrous oxide

High-dose neostigmine

Surgical events

Gastric distension

Perioperative hypotension

Patient positioning

Postoperative Risks

Pain

Nonsteroidal anti-inflammatory drug use (NSAID)

Regional medications

Opioid use

Postoperative procedures

Early ambulation

Early oral intake

Source: Compiled by Author

Table 2: SIMPLIFIED RISK FACTOR IDENTIFICATION TOOLS

Apfel et al.

Risk Factors

Points

Female gender

1

Nonsmoker

1

History of PONV/motion sickness

1

Postoperative opioids

1

Total

0–4

Koivuranta et al.

Risk Factors

Points

Female gender

1

Nonsmoker

1

History of PONV

1

History of motion sickness

1

Duration of surgery >60 minutes

1

Total

0–5

Source: Reprinted from J Perianesth Nurs, 21(4), American Society of PeriAnesthesia Nurses, ASPAN's evidence-based clinical practice guideline for the prevention and/or management of PONV/PDNV, 230-250, Copyright 2004, with permission from Elsevier.

Table 3: RELATIONSHIP OF NUMBER OF RISK FACTORS TO LEVEL OF RISK

Number of Risk Factors

Level of Risk

Increased Risk of PONV

0–1

Low

10% to 20%

2

Moderate

40%

3

Severe

60%

4–5

Very severe

80%+

Source: Reprinted from J Perianesth Nurs, 21(4), American Society of PeriAnesthesia Nurses, ASPAN's evidence-based clinical practice guideline for the prevention and/or management of PONV/PDNV, 230-250, Copyright 2004, with permission from Elsevier.

Reducing baseline risk factors can significantly decrease the incidence of PONV. Recommended strategies include [14]:

- Use of regional anesthesia instead of general anesthesia

- Use of propofol for induction/maintenance of anesthesia

- Avoidance of nitrous oxide and volatile anesthetics

- Minimization of intraoperative/postoperative opioids

Additionally, recognition and treatment of PONV in the early phases will ensure that the effects of the complication are kept to a minimum. Patients who vomit run the risk of aspiration, wound dehiscence, and a delayed return to normal function. Cardiac disturbances (e.g., bradycardia) can develop secondary to the vagal maneuvers associated with vomiting.

Prevention and treatment of PONV includes both risk reduction measures as well as medication intervention. After the patient is received into the phase I or II recovery area, measures should be undertaken to limit development of the condition. Depending on the procedure, some patients will remain NPO until peristalsis returns; however, it is important to ensure that patients are adequately hydrated. Fluid replacement measures ranging from 15 to 40 mL/kg may help to limit the development of PONV. Additionally, patients should be instructed to move slowly and be placed in the side lying position until the gag reflex has returned. Adequate pain control should be monitored using a multimodal approach. Fluid and electrolyte status should be analyzed and prophylaxis measures instituted prior to the onset of symptoms. After symptoms develop, rescue treatments in the form of medication administration can be instituted.

PONV may be prevented with the use of antiemetics prior to symptom development. Studies have shown that the administration of antiemetics prior to the discontinuation of anesthesia is most beneficial [13]. Another recommendation for limiting the development of PONV is the use of total intravenous anesthesia [13]. Patients with a history of PONV after undergoing general anesthesia with volatile gases may be candidates for total intravenous anesthesia use.

Evidence Based Practice Recommendation

According to the American Society of Anesthesiologists, antiemetic agents should be used for the prevention and treatment of nausea and vomiting, when indicated.

https://pubs.asahq.org/anesthesiology/article/118/2/291/13600/Practice-Guidelines-for-Postanesthetic-CareAn

Last Accessed: January 8, 2021

Level of Evidence: Expert Opinion/Consensus Statement

Medications used for prophylaxis of PONV include the serotonin receptor antagonists. Serotonin is a neurotransmitter that stimulates the vomiting cascade in the brain; blocking its uptake limits the incidence of PONV. Ondansetron is often considered the first-line drug, although its relative costs and incidence of headache after use have made other serotonin receptor antagonists increasingly popular. Ondansetron has greater antiemetic than antinausea effects [14,15]. Dolasetron may be considered, although its use is limited in patients with prolonged conduction defects and the drug is no longer marketed in the United States [14,16]. Granisetron has been shown to have some efficacy for PONV prophylaxis [14]. Palonosetron is a second generation receptor antagonist and has been found to be more effective at lower doses than granisetron and ondansetron in preventing PONV [14]. Ondansetron and granisetron are most effective in the prophylaxis of PONV when given at the end of surgery [14]. The administration of dexamethasone has been found to improve the efficacy of the serotonin receptor antagonists, especially when administered prior to initiation of surgery [14,17].

Other drugs used in the prevention and management of PONV include droperidol and scopolamine patches. Droperidol carries a U.S. Food and Drug Administration (FDA) black box warning, as lengthening of the QT interval has been demonstrated with doses greater than 2.5 mg. Thus, droperidol has limited benefit in certain patient populations. If droperidol is administered, ECG monitoring is recommended [16]. Scopolamine patches have had some success, often in patients who have described previous success with the patches during bouts of motion sickness. They have been found to be most effective when used as an adjunct to other antiemetic therapies [15].

Older antiemetics, including prochlorperazine and promethazine, are less effective and are often used as last resorts [15]. Both drugs should be used with caution in children [16].

The same agents may be used as rescue medications; however, dosing may be different than for prophylaxis, and the reader is directed to other sources for dosing information [13,17]. While prophylaxis remains the best defense against PONV, the medications can be used to treat break-through episodes. If one type of drug is not effective in managing the patient, another drug class is recommended. Repeating the same drug may only delay successful treatment.

Complementary therapies can also be considered and used as appropriate. The most common therapy discussed in the literature is the use of the P6 acupoint stimulation [15,18,19]. This point, located on the inside of the wrist, is frequently used in acupressure and acupuncture regimens when stomach distress is noted by the patient. Other interventions that may be considered include relaxation therapies, music therapy, aromatherapy (e.g., lavender), and herbal therapy, including ginger root [20,21,22,23].

Case Study

Patient B, a woman 31 years of age, is admitted to the phase I PACU after undergoing an abdominal hysterectomy. During the preoperative assessment, the patient noted that she is a nonsmoker, has a history of motion sickness, and is quite anxious concerning the surgery and her future prospects, as she will be "sterile" upon recovery. The report from the operating room is that the patient received inhalation anesthesia and a neuromuscular blocking agent during the procedure. Prior to discontinuing the anesthesia, the patient was administered 4 mg of ondansetron for PONV prophylaxis. Also noted was a period of hypotension caused by a significant blood loss requiring the intraoperative infusion of two units of whole blood.

Upon awakening, Patient B is quite agitated. She is moving from side to side and is not yet oriented to place and time. When questioned, Patient B states that her pain is 7 on a scale of 10. The PACU nurse administers 2 mg hydromorphone IV per order. The narcotic appears to begin to take effect, and when questioned, Patient B's pain is now reported as a score of 4. However, she is now complaining of nausea and asking for an emesis basin as she is afraid she will vomit. The nurse asks her to take slow deep breaths through her mouth and encourages her to relax.

When Patient B's complaints of nausea do not recede, the nurse contacts the physician who orders another dose of ondansetron, which is administered. Thirty minutes after medication administration, the patient's complaints of nausea have not subsided and the nurse again requests an order for an antiemetic. At this point, the physician orders a scopolamine patch be placed on the patient. Subsequent to patch placement, Patient B notes that her nausea is resolving.

Case Study Discussion

Preoperative management of Patient B's nausea was handled well. The staff had ascertained the pertinent information; had a risk factor identification scale been utilized, the patient would have been ranked at a very severe level of risk for PONV. The anesthesiologist recognized this risk and treated Patient B with an appropriate dose of antiemetic prior to the termination of surgery.

There were omissions in care that could have reduced the risk of PONV development in this patient. Prior to the first dose of ondansetron in the operating room, a dose of dexamethasone could have been administered to enhance effectiveness of the serotonin antagonist.

During the PACU phase of care, the nurse caring for Patient B instituted measures to manage both the patient's pain and nausea. However, there were extenuating circumstances that were not considered and could have reduced the development of this complication. It was noted in the operative report that the patient had an episode of hypotension and blood loss; this volume depletion most likely increased the risk of PONV. In addition, the patient may have remained volume depleted into the PACU, and no note of this was made.

The physician ordered the second PACU dose of ondansetron, which was administered without benefit. The recommendation for rescue management of PONV is to change drug classes if one is not adequate; thus, another drug should have been ordered. The scopolamine patch seemed to have a beneficial response; upon further questioning of the patient, it was discovered that whenever she had previous bouts of motion sickness the patient used patches to help her manage her symptoms. Had this information been ascertained in the preoperative phase, the patch could have been applied preoperatively or in the operating room. It is critical to gather as much information as possible to reduce these types of delays in patient management.

MALIGNANT HYPERTHERMIA

Malignant hyperthermia is a complication that normally begins in the operating room but requires continued care and vigilance for recurrence in the postoperative phase of care. Malignant hyperthermia is a disease of skeletal muscle and has genetic origins. The onset of complications begins when a triggering agent is administered to a susceptible patient. The skeletal muscles begin to contract in response to the trigger, and this hypermetabolic state leads to the marked temperature rise, which gives the disorder its name. If left untreated, the mortality rate is high. In cases that receive treatment, the risk of permanent disability exists [24,25].

Malignant hyperthermia is most common in children and male patients. Many first cases are seen in children undergoing surgical corrective procedures. The most widely recognized triggers include the volatile gases (e.g., halothane, isoflurane, enflurane, desflurane) and succinylcholine [24]. After exposure, the patient may experience muscle rigidity, beginning with the masseter muscle and followed by global muscle rigidity, a rise in body temperature, and the development of systemic metabolic acidosis. Although these signs are identified as the "classic" signs of developing malignant hyperthermia, it is possible for the patient to have minimal muscle contraction and a delayed onset of elevated fever. However, all patients experience a rapid rise in exhaled carbon dioxide, which can be identified on end tidal carbon dioxide monitors used in the operating suite. This is often the first sign of the condition. Upon recognition of the developing syndrome, the triggers are removed from the patient and immediate life-saving treatment is initiated.

Although a rise in body temperature is common with this complication, it can be controlled and limited. The other conditions that arise carry a much higher risk of morbidity and mortality. Early signs include elevated expired carbon dioxide and developing cardiac dysrhythmias, such as tachycardia and ventricular dysrhythmias, as a result of elevated potassium levels. The skin feels warm to touch, yet the core temperature remains normal. As the disorder progresses, late signs include the development of a high core temperature, which can increase as rapidly as 1°C every five minutes. Temperatures have been reported as high as 46°C (114.8°F). The continuous muscle contraction causes a rise in the serum level of ionized calcium and a subsequent rise in the serum potassium level. Coagulopathy develops as fibrinogen levels fall. A respiratory acidosis develops in response to the rising carbon dioxide levels, with the pH falling below 7. Muscle contraction causes a release of myoglobin, leading to rhabdomyolysis. If left untreated, the patient can progress to renal failure, cardiac failure, and death.

Management of malignant hyperthermia begins in the operating room and continues into the PACU. The surgical intervention has usually not begun at the time of onset; therefore, the recovery of the patient is based upon treating the disorder. Treatment is both specific and symptomatic. At the first signs of the impeding development of malignant hyperthermia, anesthesia should be discontinued and the patient administered 100% oxygen through a clean anesthesia machine. Disease-specific dantrolene is administered to reverse the disease progression [24]. Supportive therapies include treating the developing cardiac and metabolic complications.

The development of dantrolene, a skeletal muscle relaxant, changed the treatment of malignant hyperthermia. Prior to its development, the mortality rate for malignant hyperthermia was as high as 70% to 80%; with immediate dantrolene use, the mortality rate for malignant hyperthermia can be as low as 2% [25,26]. Dantrolene contains 3 g of mannitol per vial, which helps prevent the renal failure commonly seen with developing rhabdomyolysis. Dosing of dantrolene varies from 2.5 mg/kg (the common starting dose) up to 10 mg/kg, depending upon the severity of symptoms [16]. Administration is time consuming; the drug comes as a powder in the vial and must be reconstituted with sterile water without bacteriostatic agent. Shaking and warming the vial helps to dissolve the powder. It is recommended that 36 vials of dantrolene be available at all times to treat a single case of malignant hyperthermia. Once reconstituted, the drug is orange-yellow in appearance and is rapidly infused. The effects occur within minutes and include a relaxing of the muscle contractions and a fall in core temperature. If no response is seen, the drug is repeated at a higher dose.

While dantrolene may be a life-saving drug, it is only one of the many measures that should be instituted to prevent the lifelong sequelae that can develop secondary to malignant hyperthermia. As the core temperature begins to rise, neurologic effects may become apparent. The rising body temperature should be controlled with cooling measures. Iced normal saline solution is infused at a rate of 15 mL/kg [24]. Internal cooling can be instituted using cold nasogastric, bladder, rectal, and/or peritoneal lavage. Cooling blankets can be applied to initiate surface cooling; this measure is much more beneficial in pediatric patients due to their high body surface area to body mass ratio.

Normalizing fluid and electrolyte balance is critical. The patient's calcium and potassium levels should be monitored. Hyperkalemia is treated with a glucose-insulin drip; serum acidosis is treated with intravenous sodium bicarbonate at 1–2 mg/kg. A urine output goal of greater than 2 mL/kg/hour is desired and achieved with furosemide [24]. Preventing volume depletion is critical, and normal saline is administered to maintain adequate circulating volume. (Note: Lactated Ringer's solution is avoided as it can increase the risk of developing acidosis.)

Cardiovascular monitoring for developing ventricular dysrhythmias should be initiated early. Lidocaine, which was once thought to be a trigger for ventricular dysrhythmia, is used for ventricular ectopy. It is important to remember that calcium channel blockers are not recommended for cardiac dysrhythmias [24].

Once stable, the patient should not be considered cured. At some point during the management of the patient, he or she will be transferred to the PACU for continued treatment. The risk of a repeat event is 25% and can occur up to 48 hours after the first event. To prevent recurrence, the patient should be transferred to the intensive care unit (ICU) and administered dantrolene 1 mg/kg every 4 to 6 hours for 36 to 48 hours [27]. During this time period, the patient should be continually monitored for the development of delayed onset cardiac dysrhythmias.

In the preoperative arena, ascertaining a history and risk assessment for malignant hyperthermia should be performed. Any patient with a first-degree relative with a history of malignant hyperthermia is considered at risk. Patients should be asked about their previous surgical and anesthesia history as well as that of their blood relatives. Patients with bulky muscles and known muscular disorders or weaknesses (e.g., scoliosis, clubfoot) are also at increased risk. Preoperative testing using the caffeine halothane contracture test (CHCT) can be performed, although there are only five centers in the United States and Canada that perform the CHCT [24,25]. Any patient at risk should have extensive counseling and evaluation done prior to instituting surgery with volatile gases. However, it is known that patients with malignant hyperthermia can have regional anesthesia with good success.

The initial management of the malignant hyperthermia patient begins in the operating room at symptom onset. Mixing the vials of dantrolene is a time-consuming process, and many hands are needed for a successful resuscitation. After the patient is moved to the PACU, IV fluid resuscitation should be continued, lab work monitored, and a vast array of therapies instituted and continued. As mentioned previously, dantrolene is repeated every four to six hours, and it is critical that the time for repeat drug administration not be overlooked.

Although some healthcare professionals may never see a case of malignant hyperthermia, there are certain pockets of patients known to reside in certain areas (i.e., Wisconsin, Nebraska, West Virginia, and Michigan) [24]. It is thought that these pockets of high-risk patients develop as known carriers of the disease grow up and have children of their own while staying in their home communities. In these high-risk areas, it is not uncommon for the operating room arena to see a number of cases during any given period.

Whether a facility has one or twenty cases of malignant hyperthermia, the stress of managing these patients is always high. Due to the varying signs of onset, it is not always known at the onset whether a patient is developing malignant hyperthermia. The Malignant Hyperthermia Association of the United States (MHAUS) provides and maintains an enormous amount of information for both patients and healthcare providers; much of this information may be accessed at their website, https://www.mhaus.org. In addition, the MHA provides the service of a 24-hour hotline for healthcare providers, which is available by calling 800-644-9737. This line is answered by medical professionals with extensive knowledge in malignant hyperthermia development and management and can provide up-to-the-minute help when managing an acute episode.

Case Study

Patient C is a high school senior. During the opening drive in the Friday night football game, Patient C is hit from behind. When he falls, he sustains open, comminuted fractures of his left tibia and fibula. Because he is unable to stand, an ambulance is brought onto the field to transport the young player to the hospital for evaluation.

Upon arrival at the emergency department, Patient C's leg is examined, x-rayed, and evaluated by the orthopedic surgeon on call. It is determined that prompt stabilization and cleansing of the wound would be optimal for the best possible outcome; thus, Patient C is prepared for surgery. His parents, who were at the game, arrive in the emergency department just moments after the ambulance and are available to give permission for the operative procedure. As Patient C has been medicated for pain, a history is obtained from the parents. There are no notable problems; Patient C is a healthy young man in excellent physical condition. He has not had previous operations and no previous exposure to anesthesia.

Patient C is transferred to the operating room. The anesthesiologist gives the patient a number of preoperative medications, including those to prevent PONV. The anesthesia of choice is enflurane (Ethrane), a volatile gas. The patient first receives succinylcholine prior to intubation, followed by the anesthetic gas. Within minutes, the anesthesiologist notes that Patient C's carbon dioxide levels are beginning to rise. Just as the surgeon is to begin, the patient sustains a cardiac arrest.

The anesthesiologist immediately stops the insufflation of the gas and begins to administer 100% oxygen. A code response is initiated by the remaining members of the operating team. The rescuer performing chest compressions notes that the patient's skin is warm. While resuscitative efforts continue, blood for laboratory evaluation is obtained. The arterial blood gas results demonstrate a pH of 6.9, partial pressure of oxygen (PaO_2) of 110 mm Hg, and a partial pressure of carbon dioxide (PaCO_2) of 55 mm Hg. At this point, the anesthesiologist's suspicions are confirmed; the patient is experiencing an episode of malignant hyperthermia.

As soon as the diagnosis is confirmed, the staff is ordered to administer dantrolene at a dose of 2 mg/kg. The operating room personnel contact the PACU to ask for assistance in drawing up and preparing the dantrolene. Only one nurse is available to leave the PACU, and she assists with mixing and administering the dantrolene as soon as it is prepared. Additionally, the patient requires repeat doses of sodium bicarbonate to combat the falling serum pH.

Within 15 minutes of administering the dantrolene, the patient begins to demonstrate a perfusing rhythm, although this is punctuated by frequent runs of premature ventricular contractions. Antiarrhythmics are administered to control the cardiac complications.

Simultaneously, the patient is cooled with external cold packs applied to the groin and axilla areas. The leg wound is dressed to prevent further contamination during the resuscitative efforts. Repeat blood is obtained for laboratory analysis. The patient's potassium is elevated, and the patient is started on a glucose-insulin drip.

After the patient's cardiac condition is stabilized, the operating room staff request transfer of the patient to the PACU for further management. The patient is moved, and the PACU staff becomes responsible for managing the patient. The antiarrhythmics, the glucose-insulin drip, and the cooling measures are continued. During the first 30 minutes in the PACU, the patient's urine is noted to be a deep red color, indicative of developing rhabdomyolysis and potential renal failure. The patient is given 100 mg furosemide, and fluids are increased to 150 mL/hour. Within 20 minutes, the urine lightens in color, although it retains a reddish tinge.

Approximately three hours after the first cardiac arrest, the patient suffers a second arrest with the development of ventricular fibrillation. A second code response is called, and the patient is again resuscitated with dantrolene, antiarrhythmics, and sodium bicarbonate. Once again, the patient responds to treatment and regains a perfusing cardiac rhythm.

The patient is ordered to receive dantrolene every 4 hours for the following 48 hours to ensure that another episode of malignant hyperthermia does not develop. The patient is subsequently stabilized and transferred to the ICU, where he remains for 72 hours.

Case Study Discussion

Patient C is a perfect candidate for the development of malignant hyperthermia. He is a young male with well-developed musculature. He has had no previous exposure to anesthesia, so his history was not negative for anesthesia complications; it was incomplete. The onset of cardiac arrest was quite rapid in this patient. This devastating complication can be quick in onset, as demonstrated here, or may be delayed and occur later during the operative procedure. The first indication of the development of malignant hyperthermia in this patient was the rising carbon dioxide level. The skin temperature remained normal during the early phase of development; the first person to note the rise in body temperature was the rescuer performing chest compressions.

The patient was managed appropriately. The staff was required to perform a number of actions to save this patient's life. Administering medications, preparing those medications, cooling the patient, and monitoring blood laboratory values is only part of the picture. The additional PACU nurse pulled to the operating room to help with the resuscitation was instrumental in providing the additional hands and expertise needed in this case.

Upon arrival in the PACU, the patient continued to require extensive stabilization measures. The repeat dantrolene had been ordered but had not yet been administered when the patient sustained the second cardiac arrest. It is imperative that the administration of repeat doses of dantrolene be continued to prevent this type of occurrence. Fortunately, the patient was young and healthy and responded to the treatment.

Long-term outcome for this patient was excellent. The resuscitative efforts were exceptional, and the patient did not sustain any long-term neurologic deficits. It is important to point out that the patient did not have his fracture stabilized at this time. Subsequent surgery was delayed to ensure the stability of the patient. Once stable, the patient had the orthopedic repair performed with epidural anesthesia. Although the risk of developing malignant hyperthermia again while undergoing epidural anesthesia is small, dantrolene was used prophylactically to ensure patient stability throughout the procedure.

POSTOPERATIVE HYPOTHERMIA

Despite the best efforts to maintain normothermia in surgical patients, a large percentage of patients experience postoperative hypothermia [28]. Postoperative hypothermia is defined as a core body temperature of less than 36°C (96.8°F) [29]. Regardless of the core temperature, any time a patient exhibits signs of hypothermia (e.g., shivering, peripheral vasoconstriction, piloerection) measures to warm the patient should be instituted.

The causes of hypothermia may be external or internal. External causes include a low ambient operating suite temperature, the use of cold irrigants, and the length of exposure to these triggers. Internal causes include the use of general and regional anesthetics; pre-existing disease that increases the risk for hypothermia (e.g., endocrine disease, open wounds); decreased body mass, as seen with starvation and eating disorders; and medication administration, including vasodilators. Hypothermia is more common in young and old patients and in the female population.

There are many detrimental effects of hypothermia that can delay recovery. Adverse complications include a shift of the oxyhemoglobin curve to the left, leading to hypoxia development, altered drug metabolism, a decrease in the glomerular filtration rate, dangerous cardiac events (including dysrhythmia formation) and coagulopathies secondary to an altered platelet function. In addition, patients often complain of discomfort, and many will report that postoperative hypothermia was the worst part of surgery.

Managing hypothermic patients begins in the preoperative phase, when risk is analyzed. During this phase, the patient's temperature should be assessed and documented. Signs of hypothermia, including shivering and piloerection, should be noted. While awaiting transfer to the operating suite, the normothermic patient should receive preventative warming measures, including warm blankets, hats, and socks, which will limit exposure. The hypothermic patient should be warmed with active warming measures, including the use of a forced air convection system.

During the intraoperative phase of care, the patient may be exposed to cool ambient temperatures, which will further increase the risk of developing postoperative hypothermia. Patients at risk should be identified and warming measures implemented in the operating suite. Throughout the surgical intervention, the patient's temperature should be monitored by the attending anesthesia provider. While skin exposure is necessary at the operative site, utilizing passive warming measures, such as the use of warm blankets and other coverings, can be instituted on the remainder of the body surface. Should the body temperature drop precipitously, the ambient temperature can be raised and the patient can receive warm anesthetic gases.

Evidence Based Practice Recommendation

The American Society of Anesthesiologists recommends that meperidine should be used for the treatment of patient shivering during emergence and recovery when clinically indicated.

https://pubs.asahq.org/anesthesiology/article/118/2/291/13600/Practice-Guidelines-for-Postanesthetic-CareAn

Last Accessed: January 8, 2021

Level of Evidence: Expert Opinion/Consensus Statement

Upon arrival in the PACU, the patient should have his or her body temperature assessed. Normothermic patients should receive passive comfort measures to ensure patient comfort. Hypothermia patients will require active warming measures. Other measures that can be instituted based upon patient status include the warming of intravenous fluids, warming of inspired oxygen, and increasing the ambient temperature. Hypothermia patients should have their body temperature monitored every 15 minutes until normothermia is reached.

One of the consequences of hypothermia is the development of muscle contractions to maintain body temperature, also known as shivering. Postoperative shivering not only increases patient's discomfort, it can significantly increase the body's oxygen and metabolic demands. Meperidine is recommended (off-label) to manage postoperative shivering and is administered once at 12.5–50 mg IV [16,30]. The antiemetic ondansetron also has been evaluated for use in the management of postoperative shivering. A meta-analysis to evaluate the agent found no difference in the incidence of postoperative shivering when compared with meperidine; compared with placebo, ondansetron significantly reduced postoperative shivering [31]. Supplemental oxygen should be administered to thwart the onset of hypoxemia. In addition to preventing other complications, achieving and maintaining normothermia can greatly enhance the patient experience.

POSTOPERATIVE PAIN

Although pain and discomfort are expectations following surgery, inadequate pain management is unacceptable. The consequences of inadequate pain management put increased stressors upon the body, with detrimental effects. Uncontrolled pain can lead to serious medical complications, including pneumonia and DVT formation. Surgical pain can impair recovery and has the potential to progress to chronic pain. Patients with chronic pain may become depressed or anxious and be unable to carry out the activities of daily living.

Evidence Based Practice Recommendation

The American Society of Anesthesiologists recommends that pain should be periodically assessed during emergence and recovery.

https://pubs.asahq.org/anesthesiology/article/118/2/291/13600/Practice-Guidelines-for-Postanesthetic-CareAn

Last Accessed: January 8, 2021

Level of Evidence: Expert Opinion/Consensus Statement

Surgical pain is caused by many factors. The type and location of incision, the amount of retraction needed during the procedure, and the extent and duration of the procedure will all impact pain level. Organ manipulation can lead to abdominal discomfort. The type of anesthesia used will impact postoperative pain; the analgesic components should be considered. Often the practitioner assumes that the patient's pain is at the incision site when it may be secondary to an invasive device, such as an endotracheal tube, an intravenous or Foley catheter, surgical wound drain, or a nasogastric tube. Physiologic complications, such as lactic acidosis in surrounding muscles, can increase pain. Assumptions should never be made regarding pain; further assessment is always required.

Patients' perceptions of pain vary widely; patients' previous experiences with pain will impact their subsequent responses. Assessment of pain is not only a guideline. Pain is considered the fifth vital sign and should be evaluated, treated, and re-evaluated as needed [32]. A pain history or pain assessment should be ascertained in the preoperative phase of care [33]. This should include all of the following components:

- Pain intensity

- Alleviating and aggravating factors

- Present pain management

- Pain management history

- The effects of pain upon the patient

- The patient's pain goal

Assessment of pain includes a number of measures. Physiologic parameters, including elevated heart and respiratory rates and perspiration, may be signs of increasing patient discomfort. However, these signs may be masked by medications. Nonverbal behaviors, such as restlessness, agitation, crying, or guarding, can be indicators of pain but may not be evident if the patient has received paralytic agents. Verbal assessment, using pain scales, should be performed early in the postoperative period. Educating patients in the preoperative phase on how to use these scales is imperative to successful evaluation in the postoperative period. Pain that is reported to be 9 on a 10-point scale should be believed and treated. Patients' pain scores are a reflection of their previous experiences, expectations, and pain history.

Reassessment of pain should be performed whenever intervention is undertaken. Within 30 minutes of intravenous administration, the patient should be re-evaluated. Oral medications with a slower onset of action require reassessment 60 minutes after administration. Each time the patient reports a new or changed pain, assessment should be performed.

Barriers to pain management exist and prevent adequate pain control [32]. The patient may return to the postoperative area with an endotracheal tube in place, unable to verbally communicate. Despite this obstacle, the patient should be assessed using nonverbal cues and printed material. The patient may fear what the pain means in terms of outcome; a painful site may be misinterpreted as a devastating outcome. Some patients fear drug dependence and/or addiction and may not adequately report their pain. It is important to note that many patients may not be aware of the difference between pain and discomfort. A patient who was placed in an unusual position in the operating suite may be uncomfortable because he or she has a stiff neck, as an example. This discomfort is different than the pain at the incision site and is often managed differently. Education of the patient is critical to ensure that the information and pain report are as accurate as possible [32].

Postoperative pain management includes four steps:

- Education of the patient

- Prevention

- Pharmacologic measures

- Nonpharmacologic measures

Education begins in the preoperative phase and continues through the postoperative phase and in discharge instructions. Prevention of pain is known as pre-emptive analgesia. This term is used to describe the proactive use of medications in the preoperative phase or at the beginning of surgery. An example of pre-emptive analgesia would be the administration of an anti-inflammatory agent to prevent postoperative swelling.

Multimodal analgesia is the term used to describe the process of pharmacologic treatment. This method includes the administration of a variety of drugs by a variety of different routes to improve pain relief and minimize side effects [33]. An example of multimodal analgesia is the administration of a nonsteroidal agent by the intravenous route and the administration of a narcotic by an epidural catheter. Another example of multimodal analgesia would be when an "in the wound" catheter is used to instill a local anesthetic at the surgical site and a narcotic is administered by the intravenous route. Many options and combinations are available and should be considered in all patients.

Administration of pain medications includes not only different methods (e.g., intravenous, epidural) but also different techniques (e.g., bolus, continuous infusions, nerve blocks). Each patient will respond differently to these methods and techniques, and healthcare professionals should be knowledgeable regarding the various options available to the patient. Patient-controlled devices are supported by many organizations and have met with great success over the years. The American Society of Anesthesiology now encourages and supports all of these various methods [30,33].

Pharmacologic management of pain is dependent upon a number of factors. The patient's prior exposure to the drug should be assessed. Patients may be categorized as either opioid naïve or opioid tolerant. The patient's age and liver and renal function will all impact the response to medications. The kinetics of the medications (i.e., onset, peak, duration) should be appraised and taken into account when developing a pain management plan. Comorbidities and the concomitant administration of other sedation drugs should be addressed as well.

Systemic narcotics are the cornerstone of the management of moderate-to-severe postoperative pain. This drug class has the advantages of rapid onset, ability to be given by a number of routes, and general reversibility with naloxone. Tolerance may develop more quickly with these medications, so close monitoring is critical to success. Side effects include sedation, confusion, respiratory depression, nausea and vomiting, pruritus, constipation, and urinary retention. Histamine release can occur with various narcotics and should be considered when administering these drugs to asthmatics. Morphine is the gold standard to which all other system narcotics are held. It is inexpensive and provides adequate pain relief for a vast array of patients. Other narcotics to consider include hydromorphone, oxycodone, nalbuphine HCl, hydrocodone, and codeine. Meperidine is still widely used for postoperative pain management, although its use is dwindling due to associated side effects and the fact that newer, better drugs are available.

Amid the current opioid epidemic in the United States, opioid-sparing analgesic regimens are increasingly being adopted for a broad range of complex surgical procedures. Regional analgesia, acetaminophen, NSAIDs, gabapentinoids, glucocorticoids, lidocaine, tramadol, and/or the N-methyl-d-aspartate class of glutamate receptor antagonists have been shown to be effective adjuncts to narcotic analgesia [34,35,36]. The use of nonsteroidal agents, most often the administration of ketorolac, has the advantage of providing pain relief upon movement. NSAIDs do not inhibit gut function, as narcotics can. There are limited side effects when used short term, and they treat or limit inflammation in addition to pain. It is important to monitor the number of days these drugs are used, as use longer than five days is met with increased side effects, including gastric bleeding and renal dysfunction. Other pharmacologic agents used in the postoperative phase include clonidine, antidepressants, adenosine, and anticonvulsants.

Nonpharmacologic methods of pain management include physical therapies, such as back rubs, massage, and acupressure, as well as cognitive and behavioral therapies, such as imagery, distraction, and meditation. These measures should be used as a supplement rather than a substitute for pharmacologic intervention. Education and assessment are again of utmost importance. Learning what may or may not work for a patient in the preoperative phase of care can lead to successful pain management in the postoperative period.

Postoperative pain issues are extensive, and it is not the intent of this course that this information is all encompassing. Nurses and other healthcare providers need continued education on the measures and methods of pain management that improve each year. Observational studies report that education and training programs for healthcare providers are associated with decreased pain levels, decreased nausea and vomiting, and improved patient satisfaction [33]. Certain physician and nursing organizations require pain education as part of the requirement for license renewal. The intention is that this education will improve the care that patients receive on a daily basis.

COMPLICATIONS OF SURGICAL POSITIONING

Patients are positioned in the operating suite to achieve maximum access to the surgical site with minimum effect on patient safety. While this positioning may optimize outcomes, the stressors of positioning can be harmful to the patient. Awareness of at-risk patients can alert caregivers in the operative and postoperative phases to support and manage the risks prior to complication development. The length of surgery is one of the major risk factors for complication development, although this cannot be controlled; no surgeon will rush through an operative procedure to reduce positioning risks.

The majority of surgical patients are placed in the dorsal recumbent position, including patients undergoing abdominal, mediastinal, and cardiac surgeries. While this position may seem to be harmless, it is not without risks. Intraoperatively, there may be pressure on the diaphragm, leading to respiratory difficulties, and abdominal organs can put pressure on the inferior vena cava. The risks increase in obese and pregnant patients, and these patients should be placed in the left lateral decubitus position to the extent possible during the procedure. Venous pooling occurs, leading to a postural hypotension that becomes evident in the postoperative phase when the patient tries to sit or stand. Pressure point compression, leading to ischemic tissue, occurs at the elbows, sacrum, shoulder, heels, and occiput at the back of the head. The hard, flat surface and alteration of the normal curvature of the lower spine may lead to complaints of backache. Improper positioning of the extremities can lead to compression of nerves and vessels, leading to lack of muscle control in the PACU. Patients should be evaluated before, during, and after surgery to ensure that measures are undertaken to prevent these complications.

Gynecologic and urologic surgeries often require that the patient be placed in the lithotomy position. As the legs are raised, the abdominal organs are pressed onto the diaphragm and the patient may develop a decreased functional residual capacity. When the legs are lowered, patients often experience an episode of hypotension.

The Fowler's position (also referred to as the sitting or park bench position) may be used for neurosurgical approaches to the posterior head and/or neck. During these procedures, the head is often secured and flexed forward. This flexion causes compression of the outflow of blood from the head, causing facial and airway edema. This complication can lead to airway and respiratory compromise in the postoperative phase of care. Intraoperatively, the patient may experience a drop in cardiac output followed by a compensatory tachycardia and increased systemic resistance. During surgery, this compensation is generally adequate for circulatory support; complications arise when the patient is again placed in the head-elevated, supine position for transfer to the PACU. It is not uncommon for these patients to remain cardiovascularly unstable for a period of time during the initial phases of recovery. Another complication that may occur in the operating suite is the development of an air embolism. This is a life-threatening emergency that requires immediate attention and management.

Placing patients on their stomach in the prone position is used in back, rectal, and spinal surgeries. During surgery the patient experiences both chest and abdominal compression, which can lead to respiratory and circulatory problems. Positioning of the extremities is critical; overextension or flexion can lead to nerve and joint injuries. Protection of the head and face is critical, as eye abrasions and ear compression can occur. Positioning appliances, such as the Wilson frame, or rolled blankets placed under the chest are used to alleviate chest restriction. Finally, because the patient's head was rotated to allow the anesthesia provider maximum access to the patient's head and airway, the patient may awaken with significant neck pain.

The lateral position is most commonly utilized for access to the kidneys and lungs. Atelectasis of the dependent lung can occur with the pressure applied to this side during surgery. As with the patient in the prone position, eye abrasion and ear compression can occur on the side closest to the table. Rotator cuff compression can also occur in the dependent shoulder, leading to pain and limited movement in the postoperative phase.

Another complication that can occur during the operative phase is compression of the facial nerve as a result of being mask ventilated. If this compression occurs and the nerve is damaged, it is possible that the patient will awaken with a drooping in the corner of their mouth, a drooping lower eyelid on the affected side, and speech difficulties. These signs all mimic the signs of stroke, and it can be very frightening for patients to awaken to these types of symptoms. Fortunately, the facial nerve has very good regenerative capabilities. These complications will resolve, although it may be weeks before a complete return to function is noted.

Management of positioning complications is critical during the initial phases of postoperative care. If proper technique and preventative measures were undertaken in the operative phase, the development of these side effects is limited. However, when they do occur, measures should be taken to limit the effects on patients that can lead to delays in healing and discharge. Ensuring adequate circulating volume and circulatory status is imperative to assist the body in adjusting to the new postoperative conditions. Patients who remain hypotensive in the postoperative phase will not be able to compensate for the cardiovascular changes. Supporting dependent extremities with pillows or supports will ensure adequate venous return and reduce peripheral tissue congestion. If edema formation is present, ice packs may be used, assuring that their use is not contraindicated from a surgical standpoint. Compression devices (e.g., stockings) are often applied to the lower extremities to prevent DVT formation.

The pain and discomfort of these unusual positions can be managed with a variety of agents. It is imperative that those caring for surgical patients perform a thorough assessment to allow for recognition of pain versus discomfort. Lying in an unusual position can be uncomfortable rather than painful, and measures to reduce this discomfort should be performed, including proper positioning. Medicating the patient with muscle relaxants can help ease the pain and discomfort of neck and muscle strain. Narcotic use may not be necessary to manage these side effects if good postoperative care is instituted early and continued throughout the recovery period.

4. COMPLICATIONS WITHIN BODY SYSTEMS

PULMONARY COMPLICATIONS

In the postoperative phase, respiratory problems are among the most common complications [37]. The reported incidence of postoperative pulmonary complications ranges from 5% to 80%, depending upon the patient population and the criteria used to define a complication [38]. Risk reduction measures can be instituted early and continued throughout the recovery phase of care. When patients experience severe compromise, management should be fast, efficient, and definitive to reduce the risk of respiratory arrest.

Hypoventilation (also known as respiratory insufficiency) leads to hypoxemia, which progresses to respiratory arrest if left untreated. Preoperative risk factors include the presence of an active respiratory infection or asthma. The anesthesia provider may postpone a surgical intervention if a patient presents with such a situation. Patients' age can also increase the risk of postoperative respiratory complications; elderly patients exhibit decreased respiratory effort and decreased cough reflex, which prevent them from successfully handling postanesthesia secretions. Young children have decreased respiratory reserves; thus, the development of hypoventilation leads to rapid deterioration in the child. Obesity can increase the risk of complication development. Pressure on the diaphragm can lead to a decreased functional reserve capacity, and fat retains anesthetic, leading to a prolonged recovery with delayed return of the respiratory drive. Smoking increases the risks of both operative and postoperative respiratory difficulties.

Postoperative hypoventilation is often secondary to cumulative drug effects and the use of narcotics with the potential for oversedation. While this risk may not be controllable, recognition of the risk is critical to safe care. Early extubation can lead to respiratory compromise, including aspiration. Swelling of the airway (i.e., postextubation croup) is a complication seen in the pediatric population (and will be addressed later in this course).

The first signs of developing hypoventilation and hypoxemia are usually falling oxygen saturations accompanied by a decrease in ventilatory rate and/or volume. The patient is somnolent; however, this may be secondary to the anesthetic agents remaining in the patient's system. Cyanosis is a late sign, indicating risk of respiratory arrest. Monitoring patients' respiratory status is imperative during this phase; a patient who is at risk of arrest should never be left unattended.

Recognizing the early signs of respiratory complications by assessing vital sign trends and oxygen saturations can reduce the risk of further compromise. Stimulating patients when they begin to arouse by encouraging deep breathing and respiratory exercises will ensure that full lung expansion is achieved early. Supplemental oxygen may be of benefit; however, practitioners should be aware that this may mask the signs of falling oxygen saturations. Therefore, when oxygen is utilized, other assessment parameters should be performed. The cautious use of postoperative analgesics is recommended, but finding a balance between pain control and limiting respiratory side effects can be challenging. When respiratory insufficiency becomes a true complication, reversal of narcotics and/or benzodiazepines may be necessary. If reversal agents are utilized, alternatives to narcotics should be considered to ensure adequate pain management.

Aspiration

Aspiration in the postoperative period can carry a high mortality rate [39]. Patients can develop one of four aspiration syndromes. Most commonly, the airway is obstructed by particulate matter, which can lead to airway loss. Drowning is also a possibility if the volume of aspirated fluid is significant. Chemical pneumonitis carries a high mortality risk; damage to the airways and alveoli may be irreversible and result in subsequent respiratory failure and death. Finally, patients may develop an infectious pneumonia, which can be managed successfully if treated early.

Preoperative risks for aspiration include the presence of obstructed GI tract or abnormal GI motility. Patients who undergo emergent procedures require risk reduction measures to reduce the volume of the GI contents. Obese and pregnant patients are at risk secondary to the alteration in GI function and/or anatomy. The most significant postoperative risk is early extubation accompanied by an increased level of sedation.

Risk reduction requires appropriate management during preoperative care. Ensuring that the patient complied with preoperative instructions regarding NPO status is critical [40]. While guidelines allow clear liquids up to two hours prior to surgery, many physicians will instruct their patients to be without liquids or solids for longer periods of time [41]. Administration of antacids, histamine blockers, and medications to decrease gastric contents should not be routinely administered but should be instituted in any patient undergoing emergency surgery [40].

Treatment of aspiration includes the use of rapid sequence intubation techniques to ensure a clear airway. Management of the aspiration is dependent in part upon the type of aspiration syndrome. Regardless, suctioning of the airway and ventilatory support are instituted in all patients. Antibiotic therapy is initiated, and bronchoscopy may be performed in an effort to reduce the effects of chemical pneumonitis.

Outcomes from aspiration are dependent upon a number of factors, including age, patient's response to therapy, and extent of damage to the respiratory tree. While some patients may experience sudden death due to aspiration, others may survive the initial insult only to die days later secondary to overwhelming infection.

Noncardiogenic Pulmonary Edema

Noncardiogenic pulmonary edema (NCPE) is an uncommon respiratory complication that can cause sudden death in patients recovering from surgery. Signs and symptoms of this complication are typical of pulmonary edema, including a decrease in oxygen saturations, frothy sputum formation, bilateral infiltrates, and the use of accessory muscles to breathe. In cardiac-induced pulmonary edema, the pulmonary wedge pressure is elevated; in NCPE, it remains normal to low.

NCPE can be precipitated by three mechanisms. The first is caused by the rapid pushing of high-dose naloxone. This form can be prevented by the judicious awareness of medication administration and proper dosing. The remaining two mechanisms are laryngospasm or pulmonary failure secondary to a transfusion reaction, known as transfusion-related acute lung injury (TRALI).

The most common cause of NCPE is the development of an acute laryngospasm or upper airway obstruction. This blockage of the airway leads to a negative intrapleural pressure generated when the patient tries to breathe in against the obstructed airway. This negative intrapleural pressure causes an increased venous return to the right ventricle and an increased pulmonary blood flow. The increased fluid in the lungs leaks out into the capillary bed and floods the accompanying alveoli, leading to pulmonary edema. Interestingly, this complication is more commonly seen in younger, healthy males who are able to generate high negative intrathoracic pressures. These patients are able to breathe deep against the obstruction, creating this cascade of events. Elderly or debilitated patients without strong respiratory effort cannot create the pressure to generate these events.

Risk factors for NCPE include obesity, a short neck, and a history of sleep apnea. It is more commonly seen in ENT patients and patients with a history of a difficult intubation [42]. In the postoperative period, early extubation can lead to development of NCPE as the patient is unable to manage the secretions, leading to airway blockage. Suctioning the patient prior to extubation can reduce the risk of this complication. All patients with a risk factor for NCPE should be monitored for at least 60 minutes postextubation.

Management of NCPE includes performing the jaw lift maneuver and applying positive pressure ventilation in an attempt to relieve the obstruction. Lidocaine has been used to relieve the laryngospasm. Succinylcholine should be administered with assisted ventilation to manage an uncontrolled obstruction. Reintubation may be necessary for a period of 24 hours. Steroids are administered to reduce the risk of repeat laryngospasm. Supplemental oxygen should be applied to all patients experiencing respiratory difficulty.

TRALI can also cause an NCPE [43]. This complication is caused by sequestration of white blood cells in the pulmonary vasculature, leading to an increase in vascular pressure and permeability with the subsequent development of pulmonary edema. TRALI only occurs after recent blood transfusion, developing anywhere from one to six hours post-transfusion. This is not a complication of the wrong blood type being administered; it is a reaction to type-specific blood whereby the white blood cells are incompatible with the patient's body [44]. The sign of developing pulmonary edema may occur quite early during the operative phase or may not develop until hours later when the patient is in the PACU or even on the nursing unit.

Management of TRALI includes supportive ventilatory assistance. Some patients may require mechanical ventilatory support, while others will respond to oxygen therapy and the maintenance of hemodynamic status. Resolution of TRALI usually occurs within 96 hours of onset, although reported cases of continued problems have been seen up to seven days after onset. When the patient is ready for discharge, education concerning the complication is necessary. Any future interventions requiring blood transfusions should be performed with leuko-reduced red blood cells, or "washed" blood, which is blood that has undergone additional procedures to remove the offending white blood cells [44].

Case Study

Patient D is a male patient, 32 years of age, undergoing an uncomplicated bowel resection to repair damage and scarring of the bowel secondary to a traumatic automobile accident five years prior. The patient is a healthy, active male who states that he has smoked a pack of cigarettes a day off and on for the last 15 years. He had quit smoking after his auto accident but started again three years previously. His history is unremarkable for cardiovascular disease, and his anesthesia provider has reviewed his previous surgeries, performed at the time of the accident.

During surgery, the patient receives general inhalation anesthesia, intravenous narcotics, and neuromuscular blocking agents. The procedure runs approximately four hours in length. During the procedure, the patient has one short episode of hypotension that was managed with volume replacement.

Upon arrival in the PACU, the patient's vital signs are: blood pressure 118/62 mm Hg, pulse 78 beats per minute, respiratory rate 22 breaths per minute with shallow respirations, temperature 36.5°C, and oxygen saturation 91%. The patient had been extubated in the operating room just prior to transfer to the PACU. The nurse caring for the patient notes the signs and symptoms of respiratory distress, including the high respiratory rate, the shallow respirations, and the low oxygen saturation level. When the patient awakens complaining of pain, the nurse is hesitant to give too large of a dose of the narcotic that had been ordered.

After 30 minutes, the patient's respiratory rate is 18 breaths per minute, the oxygen saturation is 93%, and the patient is more alert. However, the patient continues to complain of ongoing pain, and the nurse leaves the patient's bedside to obtain the narcotics. Upon returning to the patient, the nurse finds the patient dozing. When the patient wakes, the nurse asks him to use the incentive spirometer; he had been instructed in its use in the preoperative phase of care. The patient complains of increasing abdominal pain and refuses to use the spirometer. At this point, the nurse chooses to administer 3 mg of hydromorphone as ordered for pain by the surgeon.

After receiving the hydromorphone, the patient again dozes off and appears to be comfortable. When obtaining the next set of vital signs, the nurse notices that the oxygen saturation has again dropped to 91%; however, as the patient's respiratory effort appears to be adequate, the nurse assumes this low saturation is a consequence of his smoking history. The patient has oxygen supplied by nasal prongs, and the nurse chooses not to intervene further. The patient is left sleeping while the nurse assists in the admission of another patient to the PACU.

Forty-five minutes after arrival in the PACU, Patient D experiences a respiratory arrest. The nurses immediately call a code and initiate resuscitative measures. The patient is administered naloxone, and positive pressure ventilation is initiated. However, bagging the patient is extremely difficult; the pop-off valve goes off with each ventilation, and the patient's chest is not rising as hoped.

Fortunately, the anesthesia provider responds and immediately asks for an endotracheal tube to reintubate the patient. When attempting to intubate the patient, the anesthesia provider finds it very difficult as a result of the patient developing a laryngospasm. Succinylcholine is administered, and high positive pressure oxygen is given via a jet vent. After another two attempts, the patient is successfully intubated. The patient is then placed on a mechanical ventilator with positive-end-expiratory pressure applied to help reduce the buildup of fluid in the lungs. He is started on a course of antibiotics and steroids and admitted to the ICU. After two days, the patient is extubated, moved to the surgical floor, and at day 6, is discharged from the hospital.

Case Study Discussion

Patient D is a typical postoperative patient. He was healthy and had an uncomplicated surgical event. He should have progressed through the recovery period without a problem; however, he sustained a respiratory arrest and his recovery was prolonged. Fortunately, he survived without long-term sequelae.

The nurse caring for Patient D made assumptions about his condition based upon his preoperative history. The smoking history allowed her to be lulled into a sense of security knowing that smokers have altered oxygen saturations. His appearance of ease was comforting, and she became complacent in her vigilance.

When Patient D sustained the respiratory arrest, the initial cause was unknown. He had a number of risk factors; the arrest may be been caused by the dose of narcotics, in which case, naloxone would have been a treatment of choice. This was tried but without a successful response. He was hypoxemic upon arrival in the PACU, as evidenced by his low oxygen saturations. This hypoxemic state may have precipitated the respiratory arrest. In addition, he had received neuromuscular blocking agents in the operating room and the arrest may have been secondary to residual paralytic agent. However, upon intubation he was noted to have developed a laryngospasm, which may indicate that he sustained an episode of NCPE. He was a candidate for NCPE due to his age, preoperative health status, and early extubation.

Whenever a patient sustains a life-threatening event such as a respiratory arrest, it is critical that care providers work to determine the cause. Identification of the cause can lead to the appropriate choice of a resuscitative effort. In this case, the nurse acted appropriately in administering the naloxone, although it was later determined that this was not the cause of the arrest. Despite the fact that NCPE was not considered until the patient was found to have a laryngospasm, the measures undertaken were appropriate. The only error was the complacency that the nurse exhibited towards the patient's status upon arrival in the PACU and the first 45 minutes of care. Early attention to the hypoxemic state may have prevented the development of the arrest, although this does not always make a difference in cases of NCPE.

Patient D should be educated prior to discharge regarding the development of this side effect. If further surgeries are needed, it is imperative that he be able to relate this information so that measures can be instituted to reduce the risk of respiratory compromise.

CARDIOVASCULAR COMPLICATIONS

An estimated 25% of patients experience life-altering or life-threatening outcomes when a complication develops in the cardiovascular system during noncardiac surgical procedures [45]. Postoperative hypotension and hypertension are not uncommon and generally carry a reduced risk if recognized early. However, the formation of life-threatening dysrhythmias increases the risk of death in the postoperative period. These dysrhythmias can develop immediately after surgery or during the late phases of recovery and should be monitored in any high-risk patient. Another common cardiovascular complication is the development of DVT and subsequent pulmonary embolism.

Hypotension

Hypotension in the early phases of recovery is often mistaken for hypovolemia. While hypovolemia is one of the most common causes of hypotension, it is not the only consideration when assessing the patient with a low blood pressure. Preoperative holding of medications, food, and fluids can cause a period of postoperative hypotension; however, anesthesiologists commonly correct this volume deficit while the patient is under anesthesia. Therefore, when a patient presents with hypotension this cause should be considered and ruled in or out quickly.

Another cause of hypotension is the use of volatile anesthetics, which have a vasodilator effect. These anesthetics also depress the myocardial function; thus, the circulating volume is often low and presents as hypotension. The position of patients in the operating room can cause compression of major vessels and eventual third spacing of fluids. If this is the case, the patient will present with low blood pressure, but when the patient is placed in the supine position and circulation is re-established, the patient's blood pressure will return to baseline levels.

Medications can also depress cardiac function, causing hypotension. Morphine, meperidine, and other medications that produce a histamine release can cause hypotension. Mechanical ventilation, especially with end tidal positive pressures, causes an alteration in the cardiac return and a subsequent decrease in cardiac output. High spinal or epidural sympathetic blockade used in regional anesthesia techniques can also produce a profound vasodilation and cause a patient to appear to be hypotensive. Finally, the preoperative use of antihypertensive agents can cause postoperative hypotension. These medications are often held prior to surgery, but if they are still present systemically, the patient may experience profound hypotension as a result of the dose being compounded with the anesthetics and vasodilators being used.

Risk reduction measures begin in the preoperative phase when the patient's volume status is assessed. Any volume depletion should be noted, and the anesthesiologist should be notified. Intraoperatively, it is important to ensure adequate volume to help prevent postoperative hypotension from developing. If volume loss occurs during surgery, either as blood loss or with third spacing, the patient should have volume replacements based upon these estimated losses.

Postoperatively, patients should have continued assessments of their volume status. If necessary, additional fluids can be administered at this time. Drug reversal remains an option, although this is avoided unless as a last effort. Vascular support with dopamine or dobutamine is rarely needed in these patients. Most cases of postoperative hypotension will resolve as the patient's own compensatory responses return the blood pressure to baseline values.

Hypertension

Postoperative hypertension is of significant concern due to the associated consequences of the complication, including the risk of stroke. Approximately one in three Americans is hypertensive; therefore, it is expected that many patients undergoing surgery will be hypertensive during the baseline measurement of their vital signs [46]. If hypertensive medications are held during the preoperative phase of care, it is expected that the patient will be slightly hypertensive in the recovery phase. The biggest concern is if the patient's diastolic pressure exceeds 120 mm Hg. If this is accompanied by headache, blurred vision, or changes in level of conscious, immediate intervention should be undertaken.

Hypertension can be caused by a number of factors [47]. Patients in pain who are anxious and tense may have an elevated blood pressure. Bladder and/or gastric distension can also cause a rise in blood pressure. Shivering with hypothermia can cause the pressure to rise. Some medications, such as anticholinergics, can cause a period of hypertension. Hypoglycemia produces a reflex sympathetic response, raising systolic pressure. The use of irrigating fluids may cause a hypervolemic state if they are absorbed into the vascular system.

Risk reduction is based on the cause of the hypertension. If the patient is cold and shivering, warming measures should be instituted. If the patient is in pain, pain medications may be administered. Patients who are uncomfortable due to bladder distension can have a Foley catheter placed. Management is directed at the cause, so determining the etiology is key [47]. If the blood pressure remains elevated, antihypertensive agents may be considered. However, their use is often delayed, and initial treatment should be aimed at resolving the causal condition. If the blood pressure remains significantly above baseline, medication therapy may be considered.

There are a number of antihypertensive drugs available. Diuretics may be used in cases of hypervolemia. Beta blockers are often the first-line choice when antihypertensive therapy is considered. The advantage of these drugs is their relatively short length of action; if the patient's blood pressure falls precipitously, the effects will be short-lived. Peripheral vasodilators are also available; however, these drugs are usually one of the last choices due to the significant drop in pressure experienced with their use. One rule when choosing an antihypertensive agent is to use a drug in the same class that the patient has been using for long-term management. For example, if the patient's blood pressure has been continuously managed with diuretics, administer a diuretic such as furosemide.

Dysrhythmias

Dysrhythmias can develop at any point in the management of the patient, but occur most commonly in the first four days after surgery. The presence of other complications (e.g., sepsis) should be considered in patients who develop postoperative dysrhythmia [47,48].

It is not uncommon to see dysrhythmia development after thoracic and cardiovascular surgeries. In many cases, atrial flutter and atrial fibrillation are seen; these will often convert to normal sinus rhythm without aggressive treatment. In 20% to 30% of patients, no therapeutic intervention is required [47,48]. Ventricular dysrhythmias are of greater concern, and the precipitating factors should be determined. The most common cause of ventricular dysrhythmias is hypoxia. All patients should be monitored with a pulse oximeter to allow for easy recognition of oxygen saturation values. When saturation percentages are in the low 90s or below, supplemental oxygen and respiratory exercises should be initiated. If improvement is not seen, additional therapies are needed to ensure adequate oxygenation.

Electrolyte imbalances are another common cause of postoperative dysrhythmias. Large fluid losses often result in hypokalemia, which can induce ventricular aberrations. Obtaining and monitoring laboratory values when appropriate will prevent these imbalances from becoming significant. If proactive, healthcare professionals can recognize these dangers and request orders for interventions prior to the problem becoming greater than necessary.

Deep Vein Thrombosis

Vascular compression and venous stasis that occur during surgery are major factors in the formation of DVT. Many studies have demonstrated the extent of this problem, and guidelines for prophylaxis have been issued [49]. All caregivers in the PACU should be aware of these guidelines to ensure that all at-risk patients receive appropriate prophylaxis. The American College of Chest Physicians (ACCP) guidelines for the prevention of venous thromboembolism (VTE) outline the risks and recommendations for management of DVT [50].

Evidence Based Practice Recommendation

The National Clinical Guideline Centre for Acute and Chronic Conditions asserts that venous thromboembolism prophylaxis should be offered to all patients undergoing bariatric surgery and continued until the patient no longer has significantly reduced mobility.

https://www.acutemedicine.org.uk/wp-content/uploads/2015/12/NICE-Reducing-VTE-201015.pdf

Last Accessed: January 8, 2021

Level of Evidence: Expert Opinion/Consensus Statement

The type of surgery is the primary factor in determining a patient's risk of DVT. Additional factors that affect the risk of DVT in general surgery patients include [50]:

- Traditional risk factors (e.g., cancer, previous VTE, obesity, delayed mobilization)

- Increasing age

- Type of anesthesia

- Duration of surgery

- Postoperative infection

Patients who are mobile and are undergoing an uncomplicated, minor surgical procedure are considered to be at low risk. Highest risk patients are those undergoing major lower extremity orthopedic surgeries, including hip and knee replacements (Table 4). The ACCP recommends the routine use of thromboprophylaxis following major general surgical procedures. Both low-dose unfractionated heparin (LDUH) and low-molecular-weight heparin (LMWH) have been shown to reduce the risk of asymptomatic DVT and symptomatic VTE by at least 60% in general surgery compared with no thromboprophylaxis [51].

Table 4: LEVELS OF THROMBOEMBOLISM RISK IN SURGICAL PATIENTS WITHOUT PROPHYLAXIS

Level of Risk

Approximate Deep Vein Thrombosis Risk Without Thromboprophylaxis

Successful Prevention Strategies

Low risk

(Minor surgery in mobile patients; medical patients who are fully mobile)

<10%

No specific prophylaxis; early and frequent mobilization

Moderate risk

(Most general, open gynecologic, or urologic surgery patients; medical patients, bed rest or sick)

10% to 40%

LDUH (two or three times daily), LMWH at recommended doses, mechanical thromboprophylaxis

Moderate risk

(Moderate venous thromboembolism risk plus high bleeding risk)

10% to 40%

Mechanical thromboprophylaxisa

High risk (Hip or knee arthroplasty, HFS; major trauma, SCI)

40% to 80%

LMWH at recommended doses, fondaparinux, apixaban, dabigatran, rivaroxaban, LDUH, oral vitamin K antagonist (INR 2–3), or an intermittent pneumatic compression device

High risk (Hip or knee arthroplasty, HFS; major trauma, SCI)

40% to 80%

Mechanical thromboprophylaxisa

HFS = hip fracture surgery; LDUH = low-dose unfractionated heparin; LMWH = low-molecular-weight heparin; INR = international normalized ratio; SCI = spinal cord injury.

aIncludes intermittent pneumatic compression devices, venous foot pumps, and/or graduated compression stockings; consider switch to anticoagulant thromboprophylaxis when high bleeding risk decreases.

Source: [50]

Signs of developing DVT include swelling, redness, tenderness, and a feeling of warmth over the developing clot. Homans' sign, pain upon dorsiflexion of the foot, is present. The extremity may become swollen; however, this is a late sign [47]. When signs appear, the clot has already formed and the risk is high for pulmonary emboli formation.

Risk reduction is based on a multimodal approach to management. The use of medication therapy and mechanical methods of prophylaxis are recommended for this patient group. Medications include fondaparinux, apixaban, dabigatran, rivaroxaban, LMWH, LDUH, or vitamin K antagonist. Mechanical methods include graduated compression stockings, intermittent pneumatic compression devices, and venous foot pumps. Combination therapy is also recommended for some moderate-risk patients [50].

Management of cardiovascular complications requires vigilance and astute assessment. These complications occur unexpectedly and cause rapid deterioration in the patient. Cardiac monitoring is a necessity for all at-risk patients to allow for early detection of compromise.

Case Study

Patient E, a man 74 years of age, is undergoing surgery for a blockage in his left femoral artery. The patient has a history of significant vascular compromise of his left leg secondary to the blockage. A stent is placed during surgery, and the patient is subsequently transferred to the PACU. Upon arrival in the PACU, his vital signs are: blood pressure 162/86 mm Hg, pulse 80 beats per minute, respiratory rate 16 breaths per minute, core temperature 34.5°C, and oxygen saturation 90%. The patient was extubated prior to arrival in the PACU. After the patient is stabilized and an assessment is completed, he is warmed using a warm air convection device. To combat his low oxygen saturations, his oxygen flow is increased to 6 liters per nasal cannula.

Fifteen minutes after arrival, the patient complains of severe pain in his left leg. His peripheral pulses are good, and his color is pink. However, as this was the surgical site, the nurse immediately contacts the surgeon. The surgeon speculates that the pain is secondary to new perfusion in this leg and the removal of sequestered by-products of circulation. He orders the patient to receive 3 mg hydromorphone for pain, which helps resolve the patient's complaints.

One hour after admission, the patient's vital signs return to preoperative values; his body temperature is now 36°C. At this point, he complains of pain in both lower extremities. Upon assessment, it is found that his peripheral pulses are weak in the right leg and the color of this extremity is dusky and cool to touch. His left leg remains warm, pink, and with good peripheral pulses. The patient's legs are elevated on a pillow to improve blood return to the heart, and he is again administered hydromorphone. After the second dose of hydromorphone, the patient drifts off to sleep. When he wakes, he continues to complain of pain in both extremities. The right leg remains cool, dusky, and with poor peripheral perfusion. The nurse again contacts the surgeon, who determines that the patient is possibly developing a DVT in the right calf. The patient has graduated compression stockings applied to the right leg to reduce the risk of further clot formation. As the patient had been heparinized in the operating room, no further anticoagulants are ordered.

The patient is discharged from the PACU to the surgical ward. At day 3, when he is ambulating in the hall, Patient E suffers a cardiac arrest and is not able to be resuscitated. He most likely sustained a pulmonary embolus secondary to the DVT in the right leg. The ambulation may have caused the clot to be knocked loose, allowing it to travel to the pulmonary vasculature.

Case Study Discussion

This patient was at high risk for DVT formation both due to the type and extent of surgery as well as his history of peripheral vascular disease. As he was anticoagulated in the operating room, no further interventions were instituted. However, the guidelines for management and prophylaxis of this type of patient recommend the institution of graduated compression stockings or intermittent pneumatic compression device in addition to anticoagulation [50]. It can be speculated that this may have reduced his incidence of DVT formation; however, due to his extensive vascular history, he was at high risk prior to, during, and after surgery. It would be speculation to determine if this event may have been preventable.

The nurse caring for the patient performed her job according to policy. The only change that may have been recommended is the placement of the graduated compression stockings on the right leg prior to surgery or after the patient was stabilized in the PACU.

NEUROLOGIC COMPLICATIONS

It is common to anticipate when a patient will awaken following surgery based upon the drugs the patient received, when those drugs were last administered, and patient information, such as age, weight, and health status. When the patient does not conform to these anticipated parameters, a concern that the patient suffered some type of neurologic complication begins to develop. Delayed awakening is one of the most concerning complications in the postoperative period. On the other end of the spectrum, the patient may awaken abruptly and in a confused, disoriented state, leading to what is known as emergence excitement or emergence delirium. Either of these developments will disrupt the smooth transition from the state of anesthesia to the state of full awareness.

Other neurologic events that can occur in the postoperative period include prolonged paralysis or compartment syndrome. Both of these complications affect patients' ability to move their extremities as they were able to in the preoperative period. Patients often assume that some type of life-altering complication has developed and that they may never be able to move again; in other words, they believe that they are paralyzed for life. While this is far from the truth, the anxiety and fear that these complications can generate in the patient can be overwhelming. Measures to reverse neurologic complications should be instituted immediately; in the case of compartment syndrome, delayed management can cause life-long disability.

Delayed Awakening

Regaining consciousness and awareness following anesthesia is impacted by many factors. When a patient does not awaken within 60 to 90 minutes following anesthesia, this is referred to as delayed awakening. The medications administered to achieve anesthesia are common culprits of delayed awakening. When a patient has received inhaled gases, awakening is directly related to alveolar ventilation. With poor ventilation, the gases remain in the pulmonary tree, prolonging arousal. Premedications that have a longer length of action than the procedure can cause the patient to remain somnolent during this period. Midazolam, with its short length of action, is commonly used as a premedicant to prevent this occurrence.

The half-life of medications administered in the operating suite may be long. Clearance through the typical metabolic pathways may be prolonged due to pre-existing physiologic complications. For instance, lipid-soluble drugs become sequestered in the adipose tissue and their release is slow, leading to prolonged length of action. The more adipose tissue that is present, the greater the risk of delayed metabolism and, by extension, delayed awakening. Medications may also have delayed onset and/or metabolism secondary to a slowing of circulation. Common in the elderly, this slow circulation results in delayed clearance by the kidneys, which leads to the drug remaining in the system longer and the drug effects continuing until the drug is cleared.

While the most common causes of delayed awakening include residual anesthetic or hypoventilation, other causes should be considered [52]. Both hypoxia and hypothermia can affect patient arousal. Electrolyte imbalances, hypoglycemia, or hyperglycemia can prolong awakening. These types of imbalances can produce metabolic problems that mimic delayed awakening. Although rare, drug overdose should be considered as a potential cause.

When a patient fails to awaken as expected, a treatment plan should include determination of cause, and reversal, if necessary. Reversal agents such as naloxone, flumazenil, and physostigmine may be used. These reversal agents may work for patients with residual medication; however, the awakening is often abrupt and uncomfortable, particularly when naloxone is used [16]. For patients who do not respond to these interventions, consideration of an intraoperative catastrophe should be considered. The patient may have suffered an episode of cerebral hypoxia or an intracerebral event, such as a clot or hemorrhage, leading to a stroke. These events will lead to life-long disability and/or death.

Emergence Excitement or Delirium

While many patients awaken as expected, some patients' arousals are neither smooth nor uneventful. Emergence excitement or delirium has been noted in 10% of the general surgical population [53]. Emergence excitement is defined as a state of restlessness and disorientation during arousal. Patients may be confused and unable to process their thoughts in a normal pattern. Emergence delirium is an extreme form of excitement in which the patient is shouting, agitated, and thrashing about and may be at risk for harming himself/herself or others. Patients also generally do not respond appropriately to commands [53].

Patients at risk for emergence excitement or delirium can be identified in the preoperative, intraoperative, and postoperative phases. Age and cognitive function are both predisposing factors to this complication. Emergence excitement and delirium are more common in the young and old patient populations [54,55]. Patients with an inability to process cognitive thoughts in an orderly fashion are also at increased risk. Preoperative fears and anxiety can increase the chance that the patient will not awaken in a smooth fashion [53].

Intraoperative risk factors include the type of surgery, an episode of hypoperfusion, the use of certain medications, and the combination of multiple medications [55]. Patients undergoing hip and knee replacements have an increased incidence of an agitated or confused arousal. Abdominal wall surgical patients, including women undergoing abdominal hysterectomy, and women undergoing breast surgery have a greater chance of developing this complication as well [56]. Children undergoing tonsillectomy and adenoidectomy are known to be at increased risk. The administration of certain medications, such as meperidine, ketamine, atropine, scopolamine, and droperidol, has been associated with emergence excitement [53]. When multiple medications are used, the risk increases.

During the postoperative phase, there are certain possible causes that should be ruled out. The primary cause, until proven otherwise, is a state of postoperative hypoxia [53]. This is easily identified by monitoring for low oxygen saturation levels. All patients with lower than expected saturations should have supplemental oxygen provided until their values return to the preoperative levels. Other causes that may be identified in the postoperative phase of care include hypocapnia, dehydration, hypothermia, or hypoglycemia [53]. Patients may be experiencing a full bladder or pain but have yet to develop enough awareness to communicate this. Other patients may be experiencing the effects of withdrawal from drugs and/or alcohol; these patients may not have reported substance use or dependence during the preoperative assessment. The incomplete reversal of medications may also be a precipitating factor [53].

The first priority of those caring for a patient exhibiting signs of emergence excitement or delirium is to ensure that the patient and other staff members are safe from harm. Violent movements may cause the patient to hit his or her arms, legs, or head against the side rails, so pillows should be placed to pad these areas. While restraints may be considered, their use may only increase the agitation.

The second step is to determine the cause of the agitation. Each of the possible causes should be considered one by one until etiology is determined. First and foremost, hypoxia should be investigated and oxygen saturations assessed. While oxygen therapy may be beneficial, the application of an oxygen therapy device, such as nasal cannula or a face mask, may agitate the patient further. In this case, blowing oxygen at the patient's face and mouth may be the only method of ensuring oxygen delivery. When a patient is screaming, the PACU may be disrupted, but it demonstrates that the patient is achieving maximum pulmonary ventilation, which is a good method for clearing residual anesthetic. The loudest patients will usually return to a normal state faster than those who are hypoventilating.

Evidence Based Practice Recommendation

According to the American Geriatrics Society, healthcare professionals should perform a medical evaluation, make medication and/or environmental adjustments, and order appropriate diagnostic tests and clinical consultations after an older adult has been diagnosed with postoperative delirium to identify and manage underlying contributors to delirium.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5901697

Last Accessed: January 8, 2021

Strength of Recommendation/Level of Evidence: Strong/low

Nonpharmacologic interventions are preferred over medication administration. Reorientation of the patient may be of help. Removing indwelling tubes and catheters, when appropriate, may reduce the sense of fear in the patient. If a patient normally uses reading glasses or hearing aids, these should be obtained and given to the patient. For children, having a parent at the bedside can help diminish the sense of fear. However, prior to bringing parents into the unit to visit a child who is experiencing emergence behaviors, it is critical that parents are fully informed of the child's state and are comfortable with assisting to manage their child. Often, a parent who sees a child who is uncomfortable will become anxious, and this can have the negative effect of agitating the child further.

When patients are truly at risk of harming themselves, the use of pharmacologic intervention should be considered. Midazolam has been used; however, it may also be the precipitating factor. Elderly patients may develop emergence excitement in response to midazolam administered in the preoperative phase of care [16]. In this case, an additional dose of the drug will only potentiate the problem rather than resolve it. In cases of anticholinergic-induced delirium, physostigmine can be administered [16].

Most cases of emergence excitement or delirium last less than 15 minutes. While this may seem like an eternity when caring for the patient, the complication passes quickly and generally without consequence.

Prolonged Paralysis

Evidence Based Practice Recommendation

The Society of Critical Care Medicine and the American Society of Health-System Pharmacists recommend that optimal clinical practice requires administering analgesic and sedative drugs prior to and during neuromuscular blockade, with the goal of achieving deep sedation.

https://journals.lww.com/ccmjournal/Fulltext/2016/11000/Clinical_Practice_Guidelines_for_Sustained.16.aspx

Last Accessed: January 8, 2021

Level of Evidence: Good practice statement (consensus statement)

Prolonged paralysis is commonly a complication caused by the residual effect of paralytic agents used during the operative phase of care. Neuromuscular blocking agents are used during surgery to prevent patient movement, to produce adequate muscle relaxation, and to facilitate intubation while preventing laryngospasm. In addition, these blocking agents have a potentiating effect upon inhaled gases; therefore, the anesthesiologist may choose to use these agents in an effort to reduce the amount of gas required to achieve the desired depth of anesthesia. Normally, paralytic agents are given during the procedure dependent upon their need. By the time the surgical intervention is complete and the patient has been moved to the PACU, the effects of these medications have usually worn off. However, in cases of prolonged drug effect, the paralysis may last into this recovery phase.

Between 20% and 40% of patients arrive in the PACU with objective evidence of residual neuromuscular blocking agents. Multiple investigations have demonstrated that residual neuromuscular blocking agent is an important patient safety issue, and numerous clinical studies have documented that incomplete neuromuscular recovery is associated with a variety of adverse events (e.g., airway obstruction, hypoxemic episodes) in the early postoperative period [57]. Despite the evidence documenting the importance of perioperative neuromuscular monitoring, surveys indicate that subjective assessment using nerve stimulators is performed in less than 40% of patients, while objective monitoring is even rarer (17% of patients) [57]. Failure to monitor occurs not only in adult patients but also in pediatric patients who are even more vulnerable to the sequelae of incomplete reversal [57]. PACU nurses report that residual neuromuscular blocking agent is one of the most critical events that they may face requiring emergency intervention [58].

Recovery can be tested by evaluating the following parameters: ability to open eyes wide, sustained protrusion of the tongue, sustained hand grip for at least five seconds, sustained head lift for at least five seconds, and the ability to cough effectively [59]. Achievement of certain respiratory parameters, including a tidal volume of at least 5 mL/kg, a vital capacity of at least 15–20 mL/kg, and/or an inspiratory force of 20–25 cm, may also indicate recovery. However, in many settings, evaluation using these parameters has had limited success in preventing the occurrence of residual paralysis [57].

To guide appropriate perioperative management, assessment of residual paralysis with a peripheral nerve stimulator is mandatory [57]. As the effects of paralytic agents begin to wear off, muscle recovery is noted. The order of muscle recovery is as follows: diaphragm, intercostal muscles, large muscle groups (i.e., shoulders, abdominal muscles), medium muscle groups (i.e., extremities, tongue), and finally small muscle groups (i.e., eyes, mouth, face, fingers). The peripheral nerve stimulator is used to test the responses of the small muscles in the hand and fingers demonstrating the return of function of the last muscle group.

The peripheral nerve stimulator is usually applied to the ulnar nerve at the wrist or elbow. Other sites of electrode placement include the facial nerve, the peroneal nerve, or the posterior tibialis nerve. The electrodes are applied to the skin and attached to the peripheral nerve stimulator. Commonly, the train-of-four method of testing is used [57,59]. Four rapid stimuli are applied through the electrode, stimulating the ulnar nerve, causing the small muscles of the hand and thumb to twitch. When the fourth twitch is not present, the amount of residual blockade at the motor end plates is estimated at 75%; when both the 3rd and 4th twitches are abolished, the blockade is estimated at 80%. If the second twitch is not seen, the block is estimated at 90%, and if no twitching is seen, there is 100% blockade. As the patient recovers, the amount of blockade will decrease and all twitches will be seen [59,60]. Consensus guidelines for the use of muscle relaxants in critically ill children call for the assessment of the depth of block at least once every 24 hours with train-of-four monitoring [57,61].

If the patient remains in a state of paralysis, agents are available to reverse the effects of the nondepolarizing blocking agents. Reversal agents include neostigmine and pyridostigmine [16,59]. The newest reversal agent, sugammadex, was approved by the U.S. Food and Drug Administration (FDA) in 2015 [16]. Sugammadex is a modified gamma cyclodextrin (a selective relaxant binding agent) that reverses neuromuscular blockade induced by rocuronium or vecuronium in adults undergoing surgery. These reversal agents can be administered intravenously, and the effects occur within 5 to 15 minutes after administration (or in less than 3 minutes with sugammadex) [16]. When the patient begins to regain motor function, the peripheral nerve stimulator is no longer used. While return of function occurs within minutes, the patient remains weak and should be monitored throughout the recovery period for return of developing weakness or paralysis. If the patient was administered succinylcholine, a depolarizing blocking agent, the drug cannot be reversed and return of motor function will be dependent upon clearance of the drug through normal metabolic channels [16,59].

There are a large number of factors that potentiate the development of neuromuscular blockade. It is important to assess for these factors and develop a plan of care based upon these interactions. Medications and conditions potentiating the development of neuromuscular blockade include:

- Antibiotics

- Sedatives

- Inhalation gases

- Hypothermia

- Many commonly prescribed cardiovascular medications

When these factors are present, paralysis may linger into the recovery phase, but with time and clearance of the drugs, the patient will regain function, often without the need for reversal agents.

Compartment Syndrome

Compartment syndrome is another neurovascular complication that can lead to lifelong disability if not recognized and treated early. Most commonly affecting the lower extremities, compartment syndrome develops when fluid and blood accumulate within the fascia surrounding the muscles. The fascia does not expand; thus, the increasing fluid accumulation causes an increase in the intracompartmental pressure. This increased pressure causes a decrease in circulation within the compartment and subsequent cellular death due to anoxia [62]. The most common cause of compartment syndrome after surgery is compression of tissue during surgical positioning. If the extremity is not positioned for drainage and circulatory flow, this pressure can increase, leading to compartment syndrome.

The most common sign of compartment syndrome is pain out of proportion to the injury [62,63]. There may be evidence of swelling, tenseness, and redness around the affected area; however, these may be late signs, and recognition at this point may be too late to achieve a normal outcome. Loss of peripheral pulses has often been considered a sign of impending compartment syndrome, yet pulses may be present even in acute stages of this complication. As an example, the lower leg has four compartments [63]. If one is developing compartment syndrome, the other three may be providing adequate circulation to the lower extremities, allowing pulses to remain intact despite the lack of circulation in the one affected compartment. Comparing extremity circumference from the normal to the affected side may also be used; however, due to the fact that the fascia is nondistensible, this difference is often minimal.

If unrecognized, the pain and paralysis will continue to the point of loss of function. After cellular demise begins, reversal is difficult; necrotic tissue develops, requiring surgical removal. Time of onset to the development of necrosis after ischemia is approximately six to eight hours [62]. Measuring intracompartmental pressure remains the standard for the diagnosis of compartment syndrome and can be performed using commercial or "self-made" systems. Often, evaluation by an orthopedic surgeon is all that is required. Once recognized, the surgeon performs a fasciotomy regardless of the compartmental pressure. The sooner the fasciotomy is performed, the earlier blood flow can return to the affected area and cellular repair can begin [62].

Recognition of compartment syndrome is critical to successful outcomes. It is important to be aware of the possibility of compartment syndrome development in any patient, especially those who were positioned for a lengthy surgery. Preceding trauma may also increase the risk of development; a thorough preoperative history will alert caregivers to this risk. Despite the lack of predisposing factors, any time a patient complains of pain that is considered out of proportion to the expected, compartment syndrome should be considered.

Case Study

Patient F, a woman 47 years of age, has sustained a comminuted fracture of her left tibia and fibula after falling on wet grass. Patient F is transferred to the emergency department, where the determination is made to take her to the operating room for internal fixation and subsequent casting.

Following surgery, Patient F is admitted to the PACU with a cast on her left leg. The leg is elevated on top of pillows to ensure adequate drainage. Upon awakening, the patient complains of pain of 9 on a 10-point scale. She is medicated with hydromorphone and falls back to sleep. Forty-five minutes later, she again complains of continued pain. At this point, she receives 3 mg of intravenous morphine. While reviewing the patient's chart and medication orders, the PACU nurse discovers that the patient has a history of frequent narcotic use and is labeled a "complainer" who is frequently seen in the emergency department or physician's office with vague complaints of pain and requests for refills of her narcotics.

After two hours in the PACU, the patient is transferred to the orthopedic floor for continued recovery. Other than her complaints of pain, her PACU stay is uneventful. When giving report to the nurses on the floor, the PACU nurse relays her findings regarding the patient's complaints of pain and repeat requests for pain medications.

During the remainder of the day and into the evening shift, the patient is monitored every four hours. She is medicated as ordered, but within one to two hours after receiving her medications she calls the nurse for additional narcotic. She continues to complain of pain, stating that she feels a burning sensation in her left leg. Her cast is checked and appears to be intact, without peripheral swelling of her leg, and peripheral pulses are present but weak.

At midnight, the patient calls the nurse with continued complaints of pain. The nurse notes that the cast is tight; the patient is no longer keeping it elevated as instructed. The orthopedist on call is contacted, and the decision is made over the telephone to bivalve the patient's cast to ensure adequate circulation. This is accomplished, and the patient appears more comfortable, although her reported pain score remains at 6.

The following morning the patient is seen by the orthopedic surgeon, who notes the bivalved cast and continued complaints of pain. The surgeon orders the cast to be replaced, which is accomplished. That evening the patient again complains of pain, this time giving a score report of 10. The physician is again contacted by telephone, and additional pain medications are ordered. Throughout the night, the patient continues to complain of pain despite frequent doses of narcotics.

The patient is scheduled for discharge in the morning. When seen by the surgeon prior to discharge, it is noted that the patient's foot is cool to touch and peripheral pulses remain weak. She has continued complaints of pain and does not want to be discharged at this time. At this point, the surgeon considers the possibility that the patient may be developing a case of compartment syndrome. The cast is removed, and the extremity is tense and cool, with poor color. The patient is immediately taken to the operating room, where a fasciotomy was performed. Upon opening the compartment, it is noted that there is extensive necrotic tissue that requires debridement. The remaining amount of muscle is minimal. The patient eventually recovers but with severe disability in her ambulatory capabilities.

Case Study Discussion

This patient sustained a long-term disability secondary to rapidly developing compartment syndrome. As discussed, rapid assessment and intervention is required to prevent this type of sequelae. The classic sign of compartment syndrome is pain that is out of proportion to the injury. This patient had continued complaints of pain; however, due to her history as someone who was always complaining of pain, her complaints were not taken seriously. All patient complaints should be addressed and believed; the lack of attention to these complaints led to a long-term disability in this patient.

Compartment syndrome is a common complication following fracture, and the possibility of this complication should have been recognized earlier. In fact, the first evening, when the first cast was bivalved, compartment syndrome should have been considered. It was more than 36 hours before the diagnosis of compartment syndrome was made, enough time for severe tissue necrosis to develop. Had the patient undergone a fasciotomy rather than bivalving the cast, the outcome may have been different.

This case demonstrates the need for prompt recognition of patient's complaints and consideration of all potential complications, regardless of the patient's previous history. The nurses and physicians in this case neglected the patient's pain complaints because of her prior history. The patient should have been given the benefit of the doubt, which may have allowed for earlier intervention.

This case subsequently went to litigation. The physicians involved in her care admitted to malpractice in neglecting to recognize and diagnose the development of the compartment syndrome earlier in her care when the potential for complications may have been decreased. The nurses admitted to malpractice as they chose to disregard the patient's complaints when further investigation should have been undertaken. It is a sad outcome, especially as it was a preventable complication.

VOLUME STATUS COMPLICATIONS

Patients sustaining volume status changes in the postoperative period are at risk for development of recovery-delaying complications. Under- or dehydrated patients will have inadequate circulating volume to support basic body functions, leading to renal failure, immune system failure, and delayed wound healing. Overhydrated patients will experience edema formation, both at the surgical site and systemically. This edema can impact circulation to the involved tissues, delaying healing and preventing the removal of accumulated waste products.

Volume depletion in the recovery phase of care can be due to many causes. Preoperatively, patients are instructed to remain NPO after a certain time (commonly midnight). Many patients will go to bed earlier than midnight; their intake is actually stopped at bedtime. Older patients with cardiovascular disease may be on any number of diuretics, and these drugs can lead to a volume-contracted state. These patients then enter the operating suite with a depleted volume. Intraoperatively, the patient may lose volume either through hemorrhage or inadequate volume replacement. It is not uncommon, especially during abdominal procedures, that fluid is lost to the surrounding tissues, also known as third spacing of fluid. Patients with this complication will demonstrate the signs of volume depletion even though there has been no actual loss of volume, as the volume that remains in the circulatory system is inadequate to support vital functions. Postoperatively, patients may not receive adequate volume replacement to meet their needs.

Signs of volume depletion include a decrease in blood pressure and a decrease in urine output. When patients are initially admitted into the PACU, urinary output is not measured unless an indwelling catheter has been placed. When fully awake, patients may express the need to void, at which point urine output can be evaluated. With volume depletion, the urine is concentrated and appears dark yellow. If an inadequate volume state continues, the renal system becomes compromised, leading to the risk of renal failure.

Volume replacement is calculated on the measured losses (i.e., blood loss estimates) as well as the length of time the patient has remained NPO. It is important to remember that although instructed to be NPO after a certain time, many patients have been without fluid intake for a longer period of time. The formula for volume replacement for NPO time is 2 mL/kg for each hour the patient was NPO.

Replacement fluid can be given intravenously, if warranted. Signs of impending renal failure should alert caregivers to the need for intravenous replacement. If the patient is awake, alert, and able to void, volume replacement can be done over the course of a few hours and may be accomplished by oral intake. Before advising the patient to increase oral intake, it is imperative that the patient be assessed and, if necessary, treated for PONV. One of the most common reasons that patients vomit in the postoperative period is early forced fluid intake. Preoperative or perioperative intravenous hydration therapy has been shown to be more effective at reducing PONV [64,65].

Volume overload is equally as compromising to patients as is volume depletion. Preoperative causes of volume overload are rare; it is much more common for a patient to develop a volume depletion state than an overload state during this period. However, there are a number of intraoperative risks for volume overload. Patients are given a number of intravenous medications in the operating room, and it is necessary to flush the IV tubing to ensure adequate delivery of these medications. This repeat flushing of the IV line can significantly increase the volume infused. Patients who experience blood loss during the operative procedure may have blood replacement therapy initiated. When blood replacement is performed, it is common to infuse the entire bag of blood product. If a patient loses 400 mL of blood and receives a unit of packed red blood cells, the patient ends up in a volume excess state. It is rare that the patient would receive the exact amount of blood as the volume lost.

Another cause of volume overhydration is the absorption of irrigating fluid. This can occur whenever irrigating fluid is used, and patients can develop signs of hypertension and edema formation. It is not uncommon for patients undergoing TURP to absorb 1–1.5 liters during the procedure, also known as TURP syndrome [66]. Patients can develop life-threatening complications secondary to this volume overload. TURP syndrome occurs in only 2% of patients undergoing a TURP procedure. Caregivers may therefore be unfamiliar with the syndrome and may not recognize the signs and symptoms, which include [67]:

- Excessive urine output

- Signs of pulmonary congestion (e.g., a wet cough, rales, rhonchi)

- Headache

- Signs of congestive heart failure

- Hyponatremia

- Edema formation

Pulmonary edema can lead to life-threatening respiratory difficulties and the development of severe hypoxemia. Congestive heart failure can increase stressors on the cardiac system, leading to dysrhythmia formation. Hyponatremia can lead to volume shifts within the fluid cavities. Sequestration of fluid can reduce circulation to the tissues, causing hypoxemia and tissue destruction. Without adequate circulation to the wound, healing is compromised, prolonging recovery.

Management of volume overload depends upon the severity of symptoms. Patients with mild edema can have the edematous area elevated to enhance fluid redistribution. Assisting and encouraging the use of respiratory exercises will help resolve the developing hypoxemia. In severe cases, diuretic therapy may be ordered, but judicious use is recommended to prevent a volume depletion state.

Continued assessment in the operative and postoperative phase of care can reduce the risk of volume alterations. Awareness of intake and output is critical, and monitoring patients' responses should be performed for every patient.

Case Study

Patient G is a man, 83 years of age, who is undergoing colon resection for removal of cancerous nodes. The operative procedure proceeds without complication, and the patient is transferred to the PACU without incident.

During the first postoperative hour, the patient is noted to be hypotensive, with a systolic blood pressure of 80 mm Hg. A review of the patient's history indicates that his normal systolic pressure on admission was 160 mm Hg. The patient is noted to take furosemide, hydrochloride thiazide, metoprolol, and lisinopril for blood pressure control. With this information in mind, it is obvious that the patient's systolic pressure is significantly lower than anticipated.

Upon awakening, the patient is confused and disoriented. He needs continual reminders to help orient to person, place, and time. He is not compliant with postoperative instructions and tries to remove the dressing from his abdomen. He complains of pain when asked but is not able to rate the pain on a scale of 1 to 10. He requires wrist restraints to prevent him from disrupting the surgical site.

The patient is also noted to have a history of congestive heart failure following myocardial infarction many years ago. While fluid resuscitation would be the first step in supporting the patient's blood pressure, the risk of developing further cardiac failure should be considered. Prior to instituting further management, the patient's history and medication use is reviewed.

The patient stated upon admission that he had been NPO after midnight, as instructed. He was told to take his medications in the morning with a small sip of water prior to arriving at the hospital, with which he complied. His wife told the nurses that he did not eat the food recommended on his bowel prep program the evening prior to surgery; he was anxious and wanted to ensure that his colon had been cleaned out sufficiently. His wife also noted that he had complied with the bowel prep cleansing as instructed.

The patient is administered additional intravenous fluids at a rate of 75 mL/hour. He is finally discharged from the PACU five hours after surgery and transferred to the surgical ward. On the surgical ward, his blood pressure remains low, with an average systolic pressure of 90–100 mm Hg. The patient is discharged on day 3 with a blood pressure of 102/86 mm Hg.

Case Study Discussion

This case presents the typical complication of under-resuscitation and subsequent volume depletion. The patient's response to this complication was the development of a prolonged hypotensive episode, complicated by confusion and disorientation upon awakening.

Further history should have been ascertained from the patient and the patient's wife prior to surgery. The staff was unaware that the patient had been NPO for such a length of time. When asked if he complied with the bowel cleansing as ordered, the patient replied yes; no further questions were asked to ensure how he complied, when he last ate, etc. This assumption increased the risk of compromise.

In addition, the patient took his normal blood pressure control medications prior to surgery. While holding of these medications is often done on the day of surgery, the nurses needed to recognize the potential risk this offered. Ensuring adequate resuscitation and volume status in the preoperative and operative phases of care should have been instituted.

Anesthetic agents are vasodilators. This combined with the administration of blood pressure reducing agents caused a significant drop in the patient's systolic pressure. The patient's systolic pressure remained low even at the time of discharge; it is critical to alert this patient to this development and ensure that the patient follow up with either the surgeon or the cardiologist. As the drugs cleared from the patient's body, the normal systolic pressure should have been achieved.

The confusion and disorientation that developed in the PACU was most likely a consequence of low perfusion pressure within the cranial cavity of this patient. There are a number of reasons for postoperative confusion in the elderly; those reasons should be identified and treated. In this case, had the patient received fluid resuscitation earlier in the course of care, this neurologic development may have been avoided.

Managing the elderly patient with a history of multiple disease processes, medication use, and anesthetic administration is challenging. Further in-depth evaluation and history taking is critical to ensure safe care delivery throughout the operative period.

GASTROINTESTINAL AND GENITOURINARY COMPLICATIONS

One of the major causes of GI and GU complications following surgery is the preoperative preparation that patients undertake prior to arrival at the hospital. The risk for both GI and GU complications is increased with the nutritional and fluid status of the patient prior to anesthesia. Patients are instructed not to eat prior to arrival and are kept NPO for many hours prior to the start of surgery. While compliance with these instructions reduces the risk of other complications, most importantly airway obstruction, it causes an increase in risk for GI and GU problems.

Postoperative Ileus

The absence of bowel motility after surgery is known as a postoperative ileus. There is no bowel obstruction causing this hypomotility; it is a physiologic response to surgical intervention on the abdominal tract. Postoperative ileus occurs most commonly following intraperitoneal surgery, but it may also be identified after retroperitoneal and extra-abdominal surgeries. The lack of motility leads to the accumulation of fluid and gas in the GI tract, causing bloating, pain, discomfort, and nausea and vomiting, and can extend the hospital stay of postoperative patients [68].

The most common symptoms of postoperative ileus are lack of bowel movement and absence of bowel sounds. Unlike an obstruction, in which bowel tones are present, this is an adynamic state in which there is no bowel motility and no movement of gastric contents. After surgery, the bowel regains function; the small bowel will regain function within hours. The stomach will resume function at one to two days postoperatively, and the colon will eventually regain motility at three to five days after surgery. This pattern of recovery is typically seen in patients without comorbid conditions. Complications such as sepsis, metabolic disorders, pneumonia, and trauma can significantly delay recovery times. In addition, medications commonly used in the recovery phase of care, including narcotics, anticoagulants, and antacids, can alter recovery.

When caring for a patient with an ileus, it is vital to recognize its development. The patient may be uncomfortable, often trying to move and change positions in an effort to relieve the pressure in the abdomen. The patient may complain of nausea and may vomit, and the abdomen may be distended and tympanic. The size and shape of the patient's abdomen should be monitored on a regular basis. While the ileus may resolve on its own within a couple of hours, increasing intravenous fluids may help to speed recovery. Judicious use of narcotics, which slow GI peristalsis, may be considered. When choosing medication for pain, the use of nonsteroidal agents may help to reduce the need for additional narcotics and to reduce the swelling of the bowel wall.

It is important that patients do not begin feedings until resolution of the ileus. Should the bowel remain immobile and food intake started, this food will remain in the GI tract and may increase the risk of mechanical obstruction. Beginning a diet with liquids and advancing to soft foods should be recommended for all patients upon resolution of the ileus.

Nasogastric tubes offer no benefit to the patient with an ileus in terms of recovery; however, they may provide discomfort relief if they help remove some of the accumulated gases. One study demonstrated that gum chewing helped speed up the return of peristalsis [68]. Other recommendations have encouraged early ambulation to reduce the risk of other complications, such as DVT and atelectasis. Although early ambulation has generally not been found to be harmful to the patient, it does not appear to prevent or ameliorate postoperative ileus [50,51,69,70]. While most ileus formations resolve quickly and without intervention, many patients complain that this complication is a very uncomfortable aspect of their recovery.

Renal Insufficiency

Genitourinary complications in the postoperative phase include the development of renal insufficiency, which can lead to acute renal failure (i.e., acute kidney injury) if undetected and untreated. Some of the more common causes of renal insufficiency include: dehydration and/or hypovolemia preventing adequate renal blood flow; the use of intravenous dyes; and the use of certain medications. Furthermore, development is more common in certain patient populations, including patients undergoing coronary artery bypass [68].

Although occurrence is rare (i.e., risk of 0.8%), several factors accurately predict the development of postoperative acute renal failure [68,71,72]:

- Advanced age

- Emergent surgery

- Liver disease

- High body mass index (BMI)

- High-risk surgery

- Peripheral vascular occlusive disease

- Chronic obstructive pulmonary disease requiring bronchodilator therapy

Recognition of increased risk can decrease the associated mortality; following cardiac surgery, the development of acute renal failure requiring dialysis is associated with a mortality rate as high as 40% to 70% [73,74]. Infection and cardiorespiratory complications are the most common causes of death in patients with acute renal failure [72]. One sign of impending renal failure is a low urine output with rising serum creatinine levels. Hyperkalemia is a common complication of acute renal failure [72].

Management of renal insufficiency begins with fluid challenges [72]. Based upon the age, weight, and medical condition of the patient, fluids are infused to challenge the kidneys to begin normal functioning. Furosemide may be used to correct volume overload if the patient is still responsive. All nephrotoxic agents should be avoided or used with extreme caution. All medications cleared by renal excretion should also be avoided or their doses adjusted [75].

Early recognition of renal compromise and postoperative ileus is imperative to maintaining homeostasis of the GI and GU systems following surgery. While an ileus is a common development, prompt resuscitation with fluid is important to prevent it from progressing to a more significant complication. Renal insufficiency in the early postoperative phase can be treated with fluid resuscitation with good success at preventing the more life-threatening complication of acute renal failure and the need for dialysis. Reviewing the patient's intake and output record is an important place to start the assessment of volume status, keeping in mind that the patient may have arrived at the facility in a state of dehydration and volume depletion. Ensuring adequate circulating volume is the one parameter that can prevent these two rare complications.

Case Study

Patient H, a man 34 years of age, is admitted to the PACU following abdominal surgery for colitis. In the operating room, the patient's disease was found to be extensive, and he now has an ileostomy for stool drainage. He had a large mid-line incision reaching from the pubis to the distal sternum.

Upon admission, his vital signs are: blood pressure 102/60 mm Hg, pulse 72 beats per minute, respiratory rate 16 breaths per minute, oxygen saturation 94%, and core temperature 35°C. He is somnolent but opens his eyes upon repeated commands. The formation of the stoma was discussed with the patient prior to surgery as a last choice option; however, he was unaware at that point in his care of the extent of his disease and the need for the ileostomy.

After 15 minutes, the repeat vital signs are unchanged except for the blood pressure, which is 90/58 mm Hg. His body temperature remains at 35°C. Measures to rewarm the patient are undertaken. He continues to sleep, although he is arousable. After 30 minutes, the patient's blood pressure drops to 84/48 mm Hg. It is also noted that urine output is only 5–10 mL of dark yellow urine in the Foley catheter tubing. The physician is notified, and she orders a fluid challenge of 100 mL.

After the fluid challenge, the patient's blood pressure rises to 92/60 mm Hg. Although this is below baseline, it does show improvement. However, urine output remains the same; there is no recognizable response to this fluid challenge. The ostomy drainage does increase and is measured at 100 mL of very light yellow liquid.

Two hours after admission, the patient remains in the PACU. His core body temperature remains low, and his blood pressure is below baseline. Little urine output has been noted, but ostomy output is at 250 mL since surgery. Bowel tones are heard as high-pitched squeaks. Additionally, the patient remains significantly sleepy and slow to respond to commands.

After three hours, the patient is transferred to the surgical inpatient unit. His blood pressure is 98/60 mm Hg, pulse 70 beats per minute, respiratory rate 16 breaths per minute, core body temperature 35°C, and oxygen saturation 96%. Urine output totals 30 mL since the end of surgery; ostomy drainage totals 350 mL. The patient is arousable but sleeping when not stimulated.

That same evening, approximately seven hours after surgery, the patient is awake and complaining of severe abdominal pain. His abdomen is distended; ostomy drainage now measures an additional 300 mL, and urine output is 150 mL. The surgeon is notified and the patient evaluated. At this point, the surgeon speculates that there may be leakage at the stoma site. The patient is prepped for the operating room for further evaluation.

While waiting for the surgical team to arrive, the patient begins passing a significant amount of gas into the ostomy bag. The amount of drainage remains high, but with the passing of the gas the distension begins to resolve and the patient notes that his pain has diminished. It is determined that the surgery will be delayed pending resolution of the abdominal distension.

The patient remains in the hospital for another four days. He receives instruction on how to manage his stoma and ostomy. His stoma drainage remains high for the first two days. He tries solid foods on day 3 but develops severe abdominal cramping and distension yet again. His diet is changed to soft foods, and over the course of the next week, he is eventually able to tolerate a normal diet.

Case Study Discussion

This patient was admitted following an extensive abdominal procedure. Upon arrival in the PACU, his core body temperature was low; however, this is common in patients undergoing an open abdominal procedure of extended length. The only error in care was the delay in beginning to warm the patient. Rewarming measures, using forced air warming, should be the standard of practice in this type of patient.

The patient developed hypovolemia, as evidenced by his low blood pressure. This period of decreased circulating volume could have potentiated the risk of subsequent ileus formation. The fluid challenge of 100 mL was ordered without awareness of the ostomy output. This output should be included in the volume assessment of the patient prior to reporting his vital signs. Most likely, a large fluid challenge would have benefited the patient and could have helped to prevent the ileus formation.

When the patient complained of severe pain while on the nursing unit, it was appropriate to consider the risk of failure of the stoma sutures. This is not an uncommon complication in this type of surgery, especially with the distended abdomen. However, the patient required more detailed evaluation prior to being prepped for surgery. Ileus formation was not considered because the patient had audible bowel tones. While the majority of postoperative ileus patients do not exhibit bowel tones, these tones are not uncommon for patients with a stoma and significant changes in their GI tract. One procedure that may be beneficial for these patients is the insertion of a tube into the stoma. However, with the concern of disruption of the sutures, this was not an appropriate course of action for Patient H and was not performed.

While the patient did exhibit postoperative complications, the development was not unexpected. The assessment of the patient could have been better; assessing the intake and output beginning prior to surgery may have alerted the staff to the hypovolemic state. If this had been recognized and treated earlier, the ileus formation may have been averted. However, it is not uncommon for this patient type to develop an ileus, so it is difficult to determine whether it was a controllable complication. The patient's ultimate outcome was not affected by these complications, but his recovery period could have been more comfortable and without risk had certain assessment parameters been monitored more closely.

5. COMPLICATIONS IN SPECIFIC PATIENT POPULATIONS

PEDIATRIC PATIENTS

Management of the pediatric patient in the postoperative period requires the same set of skills and interventions as for the adult patient; however, increased vigilance is necessary as children can decompensate rapidly. Awareness of the anatomic and physiologic differences between children and adults will impact care delivery. The measures undertaken to support a child should include not only the hands-on care but emotional and psychologic support as well.

Managing the airway of a child is critical to success. It is imperative to remember that the larynx is more cephalad and anterior than in the adult patient. This anatomic difference requires proper head positioning at all times. The child should be placed in the sniffing position, maintaining a jaw thrust position. Additionally, the airway diameter is narrow, and airway swelling can lead to rapid onset of airway obstruction. Ensuring good air movement through the trachea is an important assessment intervention.

Children are more susceptible to vagal and sympathetic stimuli. It is common to see large heart rate swings accompanied by blood pressure changes. Knowing the normal values for a child will allow for the accurate assessment of changes from baseline. Children also have small abdominal capacities, and air accumulation in the stomach is common, which puts pressure on the diaphragm. Children can swallow air while crying, and air can be insufflated during positive pressure ventilation. This pressure on the diaphragm can lead to a decrease in functional residual capacity in the child. In addition, renal function is not well developed in children; clearance of drugs can be delayed, and prolonged drug effects can occur. Weighing a child during the preoperative phase is important as all medications will be administered on a per kilogram basis. Hypothermia is more common in children secondary to their large body surface area in relation to their body mass. The immune system is not as well developed, putting the child at increased risk of infection and delayed healing.

Anesthetic considerations in children include the need for more inhaled gas to achieve the same depth of anesthesia as in the adult patient. However, children will emerge more rapidly due to their high minute volumes. In young children, the central nervous system is not well developed and the blood-brain barrier is permeable. Young children may not respond to drugs in the anticipated manner, and the onset of drugs may be faster. Pain responses are not as well developed in young children; pain scales that are specifically designed for children should be available and used.

Postoperative management of the child includes performing a thorough, accurate assessment and repeating this assessment on a frequent basis. Children have high oxygen demands, and postoperative oxygen therapy is common. Maintaining head position with a small towel or pillow under the shoulder blades will ensure adequate airway protection. Elevating the head of the bed to decrease airway edema is always a wise choice, with consideration of operative needs. As children are more prone to postoperative hypothermia, it is important that warming measures be instituted early. Warming intravenous fluids may assist with rewarming; however, the volume of fluid infused may be inadequate to make much of a difference in the patient's body temperature. Using forced air devices is the best method for rewarming. Another measure that has shown some success is the use of overhead heaters [76]. Due to the large body surface area of children, these devices may be of benefit in this population while their use is limited in adults.

Prevention of volume depletion is important in the management of the pediatric patient. Fluid replacement is based upon the child's weight (Table 5). Children have increased fluid loss through normal mechanisms and are therefore prone to volume depletion. Supporting the ventilatory effort of the child is necessary to prevent the development of hypoxemia. During assessment, healthcare professionals should consider using devices such as incentive spirometers; children often consider these devices to be like a game and are therefore more cooperative in performing the exercises.

Table 5: PEDIATRIC FLUID REPLACEMENT FORMULA

100 mL/kg for each of the first 10 kg

50 mL/kg for each of the second 10 kg

20 mL/kg for each kg over 20 kg

Example: 20-km child

1,000 mL for first 10 kg

500 mL for second 10 kg

Total: 1,500 mL/24 hours

Rate of administration: 62 mL/hr

Fluid choice: D5 normal saline OR D5 0.25% normal saline

Source: Compiled by Author

Assessing pain and providing pain relief is important in this patient population. The American Society of Anesthesiology recommends aggressive and proactive pain management in the pediatric population to overcome the historic undertreatment of pain in children [33]. A child's underdeveloped nervous system may respond to pain medications differently than an adult's; it is common to administer pain medications at one-half the normal dosage during the first postoperative hour. The use of the multimodal approach to pain management should be instituted. Providing alternatives to pain medications can be useful. Allowing a parent to hold a child or providing a child with a pacifier or bottle may be helpful in providing comfort. Of course, all these measures should be undertaken with the constraints of the surgery in mind.

As previously noted, common postoperative complications in children include hypothermia, nausea and vomiting, malignant hyperthermia, and emergence delirium. The interventions for these complications have been discussed in this course. Unique to children is the development of postextubation croup. Subglottic edema develops secondary to prolonged intubation, trauma during intubation, or as a result of coughing against the endotracheal tube. This type of croup is more common in young children between 1 and 3 years of age [77]. The symptoms usually occur within 30 minutes of extubation and peak at six to eight hours postextubation. The child exhibits the signs of croup, including the barking cough, stridor, and chest retractions. With treatment, these signs will subside within 24 hours. Management includes administration of cool, humidified oxygen and nebulized epinephrine. The role of corticosteroids remains controversial [78].

Management of children in the PACU includes addressing both their physical needs and their psychosocial needs. A child's response to awakening in the PACU is commonly one of fear: fear of the unknown, fear of the care providers, and fear of the lack of control. Involving parents in the care of the child is often recommended and encouraged. Parents can provide the bridge between the caregivers and the child. Parents are able to interpret the needs of their child and to assess for normal versus abnormal behaviors. Involving one or both parents in the care of a child is becoming a standard of practice in many pediatric PACUs.

Attention to detail is critical in the management of a child recovering from anesthesia and surgery. Protecting the child from harm and ensuring a safe recovery should be the foremost concern. With these considerations in mind, children recover quickly without the long-term sequelae that are more common in older patients.

Case Study

Patient I is a girl, 5 years of age, undergoing a surgical intervention to correct a congenital cleft lip and palate. She is small for her age and has had multiple difficulties with food intake. During the first year of life, it was nearly impossible for her to suck either at the nipple or on a bottle due to the shape and size of the defect. Despite multiple attempts and alternative methods of feeding, her growth has been slowed due to malnourishment. As she became able to ingest solid foods, she had difficulty with swallowing and had multiple bouts of sinus infections due to food particles being forced into the open sinuses.

In the preoperative phase of care, Patient I is noted to be quite anxious, crying in her mother's arms and shying away from the caregivers. She does not want an IV line started and throws a tantrum when this is attempted. Despite her young age, she is well aware of the multitude of interventions that occur in a hospital setting and she is determined to maintain some control over these developments. Her mother comforts her and does not appear to have much control over Patient I's behavior.

The corrective repair progresses without complication, although the surgery is long, more than six hours in length. When Patient I is transferred to the PACU, she is intubated and asleep. The surgeons do not want her to awaken abruptly and risk dislodgement of the endotracheal tube and/or damage to the surgical site. Her vital signs are stable compared to those obtained during the preoperative phase of care. She has an IV line in her right forearm, a Foley catheter, and cardiac monitoring electrodes on her chest, along with the endotracheal tube.

After Patient I is stabilized in the PACU, her mother is allowed in to see her and sit at the bedside. The mother is instructed to watch the patient and notify the nurses if she starts to awaken and reach for the tubes. The mother is overwhelmed by the change in her daughter's appearance, something she has dreamed about for the last five years.

After 30 minutes in the PACU, Patient I begins to move in bed. Her eyes remain closed but she appears to be awakening and somewhat agitated. The orders are to administer narcotics to the patient for pain; however, the patient is unable to use any type of pain scale due to the decrease in cognition. The mother is holding the child's hand when the child pulls her hand away and starts to reach for her mouth. The nurse sees this happening and is able to grasp the child's wrist and prevent her from reaching the tube and surgical site. Wrist restraints are applied to ensure that the patient is not able to repeat this potentially life-threatening action.

At 60 minutes, the patient begins to open her eyes and starts to move from side to side. She is pulling against the restraints and trying to sit up so she can reach the endotracheal tube to remove it. The nurse instructs the patient that she must lie still and that the tube must remain in place. The nurse attempts to use an illustrated pain scale, but the patient refuses to cooperate, continuing to pull at the restraints.

During this combative period, the patient's blood pressure and pulse rate continue to rise and blood is noted on the dressing around her mouth. It is imperative that something be done to reduce the risk of damage; the nurse decides to medicate the patient with the narcotic ordered to help control the agitation and allow the child to relax and perhaps fall asleep. This objective is achieved, and the patient falls asleep and appears relaxed. Her vital signs again return to preoperative values.

Ninety minutes after surgery, the surgeon enters the PACU to examine the patient. While touching the patient's dressing, the patient's eyes open; she grasps the hand of the surgeon and tries to grasp the endotracheal tube. She is shaking her head violently from side to side, and the dressing on her face begins to loosen. The physician yells for assistance, and the nurse holds the head of the child still so the tube and dressing can be re-stabilized and secured. The look in the eyes of the child is one of pure terror. By now the only way the patient is able to lash out is to kick her legs, and she is thrashing about in the bed. Her mother is trying to calm her, but the child does not appear to recognize her mother or at least does not respond to the mother's efforts.

The surgeon orders a dose of midazolam in an effort to calm the child and ensure the safety of the tube and surgical site. After administration, the child does calm down and is no longer struggling; however, she does not appear to fall asleep. She continues to have a very scared look in her eyes, and she does not appear to be fully aware of what is going on around her. Within 20 minutes, the child is dozing quietly and appears to be much more comfortable.

At two hours after surgery, the patient again awakens and is calm and cooperative. She is responding to her mother and is obviously receiving comfort from her mother's presence. She is again instructed as to the need for the restraints and is not pulling against them. She tries to talk and begins coughing against the endotracheal tube. The surgeon has ordered that the patient remain intubated for at least the first 48 hours post-surgery to ensure adequate time for the wound healing to begin. This is going to be a challenge with this patient as she is trying continually to either remove or talk around the tube.

The patient is stable at three hours and is transferred to the ICU, as she remains intubated. Report is given to the staff. While the patient is being moved to the ICU bed and her hands are free, she grabs the endotracheal tube and pulls. Fortunately, she is prevented from removing the tube, although the tube is checked to ensure proper placement. At 48 hours, she is extubated and transferred to the pediatric floor. Within four days she is discharged to home without further complication.

Case Study Discussion

This child presents a number of challenges to the PACU staff. Airway management is always the first step in stabilizing a patient who has arrived from the operating suite, and this patient did have a secure airway at the time of transfer. The concern developed when the patient began to awaken and tried to remove the tube. Had she been successful at pulling the tube, this could have been a life-threatening complication. Attempting to mask ventilate the child would be challenging with the surgical repair site preventing the achievement of a good seal with the mask. Re-intubation would have to be performed with extreme caution to prevent damage to the surgical repair.

The child was initially stable, and the recovery appeared to be without incident. However, after the child started to awaken she demonstrated many of the signs of emergence delirium, which is more common in children than adults. She was thrashing about, pulling on her restraints, and uncooperative with instructions. Her mother did not appear to be able to calm her, indicating the possibility that she was disoriented and confused.

While the nurse was aware of the need to protect the child, she chose to administer the narcotics as ordered rather than receive an order for a different medication. It may have been that the narcotic was the right choice; the patient could have been in pain, although this was not assessed due to her behavior. On the other hand, the narcotic could have caused the second bout of combativeness noted upon the surgeon's arrival. When the patient was able to grasp the endotracheal tube, it was determined that the mother had released the restraint while holding her daughter's hand. This could have been another life-threatening complication; the nurse needed to not only ensure that the mother understood the need for the restraints but also check for proper placement of the restraints when her vital signs were obtained.

Midazolam was the drug that was able to allow the child to fall asleep and awaken in a more controlled state. Although midazolam may be a cause of emergence delirium and confusion in children, it is also one of the first drugs considered in its management. For this patient, it was the right drug, although the right time may have been during the first episode of combativeness. Not all children must be medicated; however, with the risks of tube dislodgement and surgical site disruption being quite high in this child, the administration of midazolam in the earlier phase of care may have been a better choice.

This case demonstrates the multitude of issues in dealing with pediatric patients. Although patients are educated prior to the surgical intervention, this education is not fully understood and the child may not follow instructions as directed. The mother was an excellent source of comfort to her child but also put her child at huge risk by untying the restraints. Parents should have continual reminders of their place in the care of their child.

The risk of postextubation croup was not addressed but could have presented a significant challenge to this patient either in the ICU or once on the pediatric unit. The risk of this form of croup increases when the patient has remained intubated for a length of time and/or when the child fights against the tube, both risk factors in this case. Fortunately, this did not occur and the patient was eventually discharged without further incident.

Children present challenges on a daily basis in the PACU. Their risk of compromise is greater, and the complications are different. Astute care will allow for safe recovery during this period.

GERIATRIC PATIENTS

Individuals older than 85 years of age make up one of the fastest growing segments of the population in the United States [79]. This increase in longevity makes it is inevitable that geriatric patients will undergo an increased number of surgical interventions. More than 40% of procedures performed in the United States are performed on patients older than 65 years of age [3]. Additionally, this age group has longer hospital stays and utilizes more healthcare resources than any other age group [3]. The existence of comorbid diseases increases with age; these chronic conditions can delay recovery. Thus, managing care for geriatric patients is a large part of the postoperative picture. Awareness of the changes that occur with aging and their significance to care will ensure safe care delivery.

Preoperative assessment is a critical part of care delivery in the geriatric population. An extensive, thorough history should be ascertained, including the presence of comorbid diseases that increase the risk of postoperative complications. A list of prescribed and over-the-counter medications and a history of the last doses of these drugs should be obtained. Prediction of risk and mortality is difficult, but measures can be undertaken to help determine if patients are at risk for either intraoperative or postoperative complications. If time allows, ambulatory ECG monitoring for 24 hours may be employed. Signs of silent ischemia should be noted and can direct the course of care during the intraoperative period.

Additional assessment should be directed at recognizing patients who are malnourished. Due to financial restraints, many elderly patients will not be able to spend money on well-balanced meals, leading to malnourishment. The loss of body proteins can affect the metabolism, onset, and clearance of highly protein-bound drugs. On the other end of the scale, obese geriatric patients are at risk of prolonged drug action when administered drugs that are highly lipid-soluble. The pharmacokinetics of drugs used for these patients should be assessed based upon the history and physical state prior to their administration.

As humans age, the cardiovascular system deteriorates. The myocardium is less sensitive to catecholamine release, and cardiac output drops by half [80]. The vascular system stiffens, and responses to blood pressure changes are not as beneficial, causing compensatory responses to be blunted. This weakening of the cardiovascular system impacts elderly patients' responses to medications; the lower cardiac output leads to a slower onset of drug action and longer length of drug action secondary to slower metabolism.

As the respiratory system ages, there is a decrease in total lung surface area, an increase in the ventilation to perfusion ratio, and a decrease in the cough reflex. Patients may develop an inadequate removal of carbon dioxide and an increased work of breathing. The loss of the cough reflex can lead to an accumulation of secretions and an increased risk of postoperative pneumonia or respiratory infection. Respiratory complications encompass the largest group of problems in the postoperative elderly patient [81]. Astute care is required to prevent respiratory failure in this patient population.

Neurologically, there is a loss of neurons with age, leading to alterations in function. Responses to medications can be altered, and neurologic assessment may be more difficult. Preoperative neurologic function should be evaluated as a baseline for comparison in the recovery phase of care. Fluid and electrolyte imbalances become more common as the body ages, and patients often take an increasing number of prescribed and over-the-counter medications. With diminished neurologic awareness there is an accompanying loss of protective mechanisms, putting the patient at increased risk of injury and falls.

Measures to manage and limit postoperative complications in geriatric patients are the same as those in adult patients. However, priority in management should be directed at supporting the cardiovascular and respiratory systems. Maintenance of ventilation and the optimization of gas exchange are critical in preventing postoperative hypoxemia. Ensuring cardiovascular stability with judicious assessment of volume and fluid and electrolyte status is imperative to prevent cardiac events.

Medication administration in the elderly patient can present a challenge. Cardiovascular changes cause the slow onset of drugs, and renal deterioration leads to a prolonged clearance of drugs. In addition, comorbid diseases may require medication administration, leading to cumulative drug effects. When administering medications to the elderly patient, the recommended method is "Start Low, Go Slow" [30,33,82]. This method will allow time for adequate onset and assessment of the effects on the patient. As an example, orders for postoperative narcotics are generally decreased during the initial phases of recovery [30].

Managing pain in the geriatric patient can also be difficult. The presence of comorbid diseases can impact pain responses. Older patients have different attitudes to pain than younger patients; their pain is often neglected and/or underreported [33,83]. Changes in cognition require the use of pain scales that can take these alterations into account. Utilizing the titration method to manage pain can limit the oversedation that is common with many of the commonly used pain medications. Providing comfort measures will have the benefit of making the patient more comfortable. The awkward positions required in the operating room may greatly increase discomfort in the elderly patient with stiff joints and arthritis. Ensuring comfort with pillows, back support, and light massage will be greatly appreciated.

The elderly patient is vulnerable to hypothermia during the recovery phase [81]. The loss of subcutaneous tissue enhances the loss of body temperature. Shivering will significantly increase the metabolic rate of geriatric patients; this patient population does not have the reserve available to meet these increased demands. Providing warm blankets, utilizing forced air heating, and warming both oxygen and intravenous fluids can reduce this risk. It is important to note that external warming devices should be used with caution; the thin skin of elderly patients increases their risk of burns and tissue destruction.

One of the most commonly encountered complications in the management of the elderly patient following surgery and anesthesia is the development of emergence confusion/disorientation or a delay in awakening. Emergence delirium, which has been discussed in this course, is only one facet of this complication. The elderly patient may indeed be demonstrating emergence delirium secondary to hypoxemia and drug administration. However, it may also be possible that the patient suffered a neurologic event, such as a stroke, while under sedation. This type of complication may not be recognized while the patient is under deep anesthesia. When the patient is expected to awaken and does not, or awakens with a neurologic deficit, this type of devastating event should be considered.

Delayed awakening can also be caused by cumulative drug effects. The half-life of most drugs is significantly lengthened in elderly patients, and repeat dosing may lead to accumulation of the drug within the central nervous system. Allowing time for the patient to awaken naturally and slowly will be much more successful than utilization of reversal agents, if available. Reversal agents can cause an abrupt change in the physiologic responses to medications and are very uncomfortable to patients. If the patient does not awaken within one to two hours, repeat assessment and consultation with a neurologist may be considered.

Another possible cause of delayed awakening is hypothermia. Hypothermia causes multiple complications, and these complications, including a shift in the oxyhemoglobin curve and a decrease in the glomerular filtration rate, can cause the patient to remain somnolent for a long time during recovery. Warming the patient and encouraging good respiratory effort once awake can speed the arousal and orientation of this patient population.

Care of geriatric postoperative patients will often continue long into the post-recovery phase. Ensuring that the patient will receive continued care, whether at home or in a nursing care facility, is critical prior to discharge. Also, it is imperative that each patient's wishes are identified in an advanced directive. This advanced directive should be reviewed with the patient prior to the administration of any sedating or mind-altering medications. A responsible adult should be identified who can act as a spokesperson and advocate for the patient [84].

With the improvement and advances in technology, more and more procedures are available to the elderly patient. Twenty years ago, this patient group may not have been considered good candidates for many of the surgical interventions that are being performed today. It is critical that the stressors of anesthesia and surgery are identified and compensated for to assist elderly patients with the best success at returning to a functional lifestyle at the time of discharge.

Case Study

Patient J is a man, 87 years of age, undergoing surgical repair of a fractured hip. He was living at home independently when he slipped and fell in the bathroom, fracturing his right femoral neck. He was on the floor for an indeterminate amount of time prior to being found by a neighbor who checked on him when he had not been seen for a number of hours. Emergency service personnel were called. They found the patient on the bathroom floor in a confused state. He was unable to accurately note the date or time, and he had no recollection of how he ended up on the floor. During the head-to-toe assessment, it was noted that Patient J had sustained a small scalp laceration over his right temporal region, which was clotted by the time the ambulance personnel arrived. His leg was in a displaced position, and a fractured hip was suspected. He was also noted to have a healed scar on his sternum, indicative of a previous open-heart procedure.

Upon arrival in the emergency department, the patient is evaluated by orthopedic, cardiology, and neurology specialists. His history is reviewed and reveals a previous open-heart procedure eight years prior to admission, a long history of smoking prior to the cardiac procedure, and a history of lifelong obesity. The patient's skin condition is poor; he has multiple bruises in varying stages of healing. He has multiple folds of fatty skin, and between these folds, the skin is quite dirty and foul smelling, indicating a poor hygienic state. He has a list of medications in his wallet, which identifies the following drugs: digoxin, simvastatin, furosemide, potassium chloride, amlodipine, and lisinopril. Due to his current state of confusion, the accuracy of this list and the last time the patient took his prescribed medications are unable to be determined.

Patient J's greatest immediate need is stabilization of the fractured femur. The neurologist deems that it is appropriate to perform the surgery under general anesthesia and that postoperative neurologic assessment should be initiated. The cardiologist agrees that the patient is stable from a cardiac standpoint and that he will most likely be able to tolerate the effects of anesthesia. The orthopedic surgeon performs the fractured hip repair.

Upon transfer to the PACU, the patient is still asleep; he was extubated in the operating room, has a cardiac monitor on and a Foley catheter in place, and his hip is positioned for optimum healing. His vital signs are: blood pressure 162/100 mm Hg, pulse 80 beats per minute, respiratory rate 22 breaths per minute, oxygen saturation 89% on 4 liters nasal prongs, and core temperature 34.5°C. No urine is noted in the Foley catheter. The greatest initial concern is the lower oxygen saturation; the nasal prongs are replaced by a face mask at a flow rate of 6 liters per minute. Within 15 minutes of switching the oxygen delivery device, the oxygen saturation increases to 91%.

Thirty minutes after arrival in the PACU, the patient remains asleep. His vital signs are stable; however, his body temperature remains at 35°C despite forced air warming. He is not moving nor does he appear to be in any discomfort. His skin condition does not appear to have improved. His lower extremities are cool to touch, and peripheral perfusion is poor.

At approximately 40 minutes after arrival in the PACU, the patient sustains a cardiac arrest. Resuscitation efforts continue for approximately 20 minutes without success, and the physician in charge pronounces the patient dead.

Case Study Discussion

This patient is representative of the typical postoperative geriatric patient. He has multiple health issues and takes many medications. His physical status is compromised by his nutritional status, in this case obesity. He was living independently prior to this event; he did not have family close by, and his history was only ascertained by the information that his neighbor and the first care responders were able to locate. Even with that, the accuracy of this information was questioned. Prior to the fall, the patient had been happily living his life, which was subsequently lost after the surgery.

After the patient was pronounced dead, it was speculated that he had developed a clot that occluded his pulmonary vasculature. If this was indeed the case, the outcome would not have changed despite the resuscitation efforts. However, due to his advanced age and condition, a postmortem exam was not performed and the cause of death was never confirmed.

The patient's condition was compromised by a number of factors. He had a positive cardiac and smoking history and may have sustained a neurologic event at the time of the fall, or a neurologic event may have precipitated the fall. His obesity presented a number of issues. His skin condition was quite poor, and his apparent lack of hygiene would increase his risk of postoperative infection. While he was considered to be independent, his current health state was definitely not optimal.

Had this patient survived, in all likelihood he would not have been able to return to an independent living environment. He would have required care in a rehabilitation facility to learn to ambulate post-surgery. Whether he would be strong enough to recover to a fully independent state was questionable.

This case demonstrates the many issues and challenges in managing the elderly patient. The lack of concrete information in the preoperative stage can impact the decisions that are made in the operating suite. Patient J's poor health status put him at increased risk for complication development. Even if the patient had survived, his long-term outcome would have been significantly different than the lifestyle he had prior to the injury. Preparing the patient and family for these less than optimum outcomes should be considered part of the preoperative care measures.

MORBIDLY OBESE PATIENTS

As morbid obesity (also referred to as severe obesity or class 3 obesity) becomes an increasingly common condition in our society, the need and desire for bariatric surgery has exploded [85,93]. Morbidly obese patients (defined as persons with a BMI of 40 or greater) are requesting surgical intervention to put an end to the risk they are exposed to when overweight [86]. Morbid obesity increases the risk of hypertension, diabetes, hyperlipidemia, coronary heart disease, and stroke [87]. These conditions increase the risk of complication development when undergoing surgery, including bariatric surgery.

There are two major types of bariatric surgery: those that restrict the limit of intake and those that restrict absorption. Restrictive procedures, including gastric banding and sleeve gastrectomy, reduces the amount of food the stomach can hold. Malabsorptive procedures, including biliopancreatic diversion with duodenal switch (BPD/DS), divert the gastric contents so the food bypasses the small intestine where food and nutrient absorption occur, preventing absorption. The criterion standard of bariatric surgery, Roux-en-Y gastric bypass, combines both malabsorption and restrictive techniques [94]. These types of procedures are associated with a weight loss of 40% to 80% of excess weight in patients, with a maintenance of approximately 50% or greater at five-year follow-up [87,94]. The other advantage of bariatric surgery is reduction or removal of life-threatening complications of obesity. In one study, 77% of bariatric surgery patients with preoperative diabetes no longer required medication after weight loss [87]. The most effective surgery for patients with diabetes is BPD/DS [94]. Ten of 11 randomized controlled trials from around the world that compared surgery with medical treatment of type 2 diabetes found surgery to be superior at achieving remission of diabetes or glycemic improvement. Surgery was also superior at improving weight loss and reducing medication burden [88].

Management of morbidly obese patients requires assessment and intervention not only on the physiologic level but also on the medical and psychologic level. These patients have numerous health issues that should be addressed, and the emotional and psychologic impact of the disease is significant. Many of these patients come to the surgeon's office hoping that the surgery will solve their problems and are not willing or able to address the multitude of issues associated with their condition and the surgery. Often, their hope is that minimal effort is required for weight loss.

Postoperative management is challenging. Studies have demonstrated that when a surgeon and facility manage these patients more frequently, the risk of complications decreases [87]. Familiarity with the postoperative complications allows for better patient management. Mortality rates range from 0.1% to 2% [87]. The risk of death is higher in men, patients with advanced age, cases of severe obesity (i.e., BMI ≥50), and patients with comorbid conditions [87].

Evidence Based Practice Recommendation

According to the American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic and Bariatric Surgery, respiratory distress or failure to wean from ventilatory support following bariatric surgery should raise suspicion and prompt an evaluation for an acute postoperative complication, such as pulmonary embolus or anastomotic leak.

https://asmbs.org/app/uploads/2014/05/AACE_TOS_ASMBS_Clinical_Practice_Guidlines_3.2013.pdf

Last Accessed: January 8, 2021

Level of Evidence: D (Regardless of the presence or absence of strong subjective factors, the absence of a two-thirds consensus)

There are several complications common to bariatric surgery. Nausea and vomiting occur in up to 50% of postoperative patients [87]. Dumping syndrome, which includes diarrhea, occurs in up to 70% of patients [89]. A multitude of fluid and electrolyte imbalances occur as absorption is altered. Additionally, there are a number of surgical complications that may develop, including anastomotic leaks, strictures, bowel obstruction, adhesions, hernias, and cholelithiasis [90].

Due to the multitude of health issues that obese patients experience preoperatively, there is an increased risk of additional complications in the postoperative period. These patients have an increased risk of DVT, pulmonary embolism, and depression. Despite the risks, the benefits generally outweigh the complications. Reversal of the life-threatening complications of obesity is achieved, and longevity can be extended.

Management of bariatric surgery patients in the postoperative period is the same as for any other patient undergoing abdominal surgery. However, the patient's history of comorbidities should be considered and these complications managed. It is important to assess for respiratory insufficiency when the patient returns to the PACU. If the patient is in the supine position during the surgical procedure, the weight of the abdomen will displace the diaphragm upward, limiting the respiratory excursion effort. This results in decreased ventilation. If this is the case, the patient will demonstrate hypoxemia and hypercapnia during the recovery period. The head of the bed should be elevated to help reduce this pressure on the diaphragm and maximize lung expansion [89].

Abdominal pain or left shoulder pain or tenderness can be a sign of anastomotic leak. Other signs include tachycardia, fever, elevated white blood cell count, and oxygen desaturation. These changes should be reported to the surgeon immediately; if not treated, these leaks carry a high mortality rate. Treatment can vary from a re-operative procedure to placement of an abdominal drain.

The physical care of this patient also presents a challenge. The patient may not fit onto a standard PACU stretcher and, therefore, should be managed on a stretcher that has been built to support the additional weight. Obese patients also often have skin care issues. They may not have been able to reach and access skin folds, so organisms can accumulate in these areas. Decubiti formation is also possible. These patients have a difficult time moving and rotating from side to side; thus, they tend to remain in one place, with poor circulation to the dependent area.

Managing postoperative diabetes is critical. Swings in blood sugar levels can occur following weight-loss surgery, as the patient's metabolic system has been altered. Check blood sugar regularly and administer insulin, as needed, to prevent blood sugar surges. Following sequential laboratory values can alert healthcare professionals to the development of electrolyte imbalances, including shifts in potassium, chloride, and calcium levels.

Case Study

Patient K is a woman, 42 years of age, who weighs 432 pounds. She has a BMI of 62 and is scheduled to undergo a restrictive bariatric procedure. Her history is positive for hypertension, diabetes controlled with two to three insulin injections daily, gastroesophageal reflux disease, and obstructive sleep apnea. She is nervous prior to surgery, yet anxiously awaiting the new life that she sees in her future.

The operative course of care is unremarkable. The patient has a gastric band placed, creating a small pouch. She is transferred to the PACU having been extubated. Her vital signs upon admission are: blood pressure 182/112 mm Hg, pulse 82 beats per minute, respiratory rate 24 breaths per minute, core temperature 35°C, and oxygen saturation 91%. She remains very somnolent but opens her eyes with loud verbal stimulus.

Upon admission, the concern for this patient is the low oxygen saturation. She maintained a saturation of 94% during the procedure but the postoperative saturation remains 90% to 91%. Oxygen is being delivered by nasal cannula at 4 liters/minute. The nurse caring for the patient is unsuccessful at awakening her for more than a few seconds. The oxygen delivery system is changed to a face mask with a liter flow of 6 liters/minute. Little improvement in the patient's status is seen with this change.

It would be optimal to awaken the patient to have her participate in respiratory exercises; however, she remains quite sleepy while in the unit. Elevating the head of the bed may help her oxygenation but does little to increase her oxygen saturation values. Arterial blood gas analysis is obtained; the results are: pH of 7.34, PaO_2 of 74, and PaCO_2 of 47. With these results it is obvious that the patient is hypoventilating, most likely secondary to pressure on the diaphragm limiting her respiratory excursion effort.

The patient remains somnolent for the next four hours. Her oxygen saturation values remain around 91% despite the efforts of the staff. After four hours in the PACU, she is transferred to the inpatient unit for an overnight stay. She remains hypoxic until the following afternoon.

Case Study Discussion

The patient in this case study demonstrated one of the more common complications following bariatric surgery: hypoventilation. The upward displacement of Patient K's diaphragm prevented full expansion of her lungs, causing carbon dioxide levels to rise while oxygenation values remained low. Although the levels were low, they were not to the point of being life-threatening.

One measure that may be used to improve oxygenation in patients following surgery is respiratory exercises to help expand the lungs and encourage the patient to expel secretions. To accomplish this goal, the patient should be cooperative and have an appropriate cognitive level to follow the commands. As this patient remained somnolent for a lengthy period, efforts at obtaining her cooperation were unsuccessful. It is not uncommon for obese patients to experience a delay in awakening following anesthesia. The drugs are absorbed into the fatty tissue, and release occurs over an extended period of time. One measure that may have been successful in arousing the patient more quickly is a fluid challenge. This extra fluid can often help circulate the remaining anesthetic and speed the metabolism of the medication, allowing the patient to awaken more quickly. While this may not always be the answer to delayed awakening, it is often successful in obese patients.

Fortunately, this patient did not experience any of the other postoperative complications that are common following bariatric surgery. After her respiratory status improved, she was able to meet the criteria for discharge and was sent home the next day.

In follow-up with this patient, she lost more than 100 pounds in the first year following surgery. She started an exercise regimen and is determined to continue with her weight loss. While 100 pounds is quite a bit of weight to lose, her weight is now 330 pounds; therefore, she remains at risk for the complications of obesity. Her diabetes has not resolved, yet she remains hopeful that with continued weight loss she will one day be free of insulin injections. Morbidly obese patients have a long and often arduous path ahead of them and should not expect miracles to happen overnight.

6. CONCLUSION

Postoperative complications have a negative effect upon surgical outcomes. Patients can experience delayed healing and delayed release from the hospital and can risk life-threatening or life-changing sequelae. The cost of postoperative complications is estimated at millions of dollars per year [91]. If these complications can be controlled, the benefits to patients and the healthcare system can be significantly improved.

Management of postoperative complications encompasses all phases of patient care. Beginning in the preoperative area, those caring for the surgical patient should obtain an accurate, thorough history. A preoperative assessment should be performed, as discharge of the patient is often based upon the data documented during this assessment. Intraoperatively, risk reduction measures can be instituted to limit the development or progression of postoperative complications. Healthcare professionals working in the PACU have the task of ensuring the safe recovery of the patient while minimizing complication development. Risk-reduction measures should be initiated during all patient interactions and should include thorough assessment and preventive measures.

It is important to develop the skills to recognize patients at risk and help develop policies to reduce complication development. If this is accomplished, patient outcomes will improve.

7. GLOSSARY OF TERMS

AORN: the Association of periOperative Registered Nurses, a professional nursing organization.

ASA: the American Society of Anesthesiologists, a professional medical organization.

ASPAN: the American Society of PeriAnesthesia Nurses, a professional nursing organization.

Body mass index (BMI): the weight in kilograms divided by the square of the height in meters.

Deep vein thrombosis (DVT): a clot that develops in the deep vasculature, commonly in the lower legs.

Hypothermia: a core body temperature of less than 36°C (96.8°F).

Inhaled anesthesia: anesthesia achieved by providing volatile gases.

Malignant hyperthermia: a rare but life-threatening disorder of the musculature causing a rapid rise in body temperature during the initial phases of anesthesia.

Morbid obesity: a BMI of 40 or more. Also known a severe obesity or class 3 Obesity.

Multimodal analgesia: the administration of a variety of drugs to improve pain relief and minimize side effects; may be given by different routes.

Noncardiogenic pulmonary edema (NCPE): a disorder causing severe respiratory distress and failure.

Perioperative period: includes the preoperative, intraoperative, and postoperative phases of care.

Postdischarge nausea and vomiting (PDNV): nausea and/or vomiting that occurs after discharge from the healthcare facility.

Postoperative nausea and vomiting (PONV): nausea and/or vomiting that develops within the first 24 hours following anesthesia.

Total intravenous anesthesia: anesthesia that is obtained only using IV agents; no inhaled gases are used.

Transfusion-related acute lung injury (TRALI): a respiratory disorder occurring within four to six hours following administration of blood products

Works Cited

1. Flood KL, Rohlfing A, Le CV, Carr DB, Rich MW. Geriatric syndromes in elderly patients admitted to an inpatient cardiology ward. J Hosp Med. 2007;2(6):394-400.

2. American Academy of Orthopaedic Surgeons. 2.5 Million Americans Living with an Artificial Hip, 4.7 Million with an Artificial Knee. Available at http://newsroom.aaos.org/media-resources/Press-releases/25-million-americans-living-with-an-artificial-hip-47-million-with-an-artificial-knee.htm. Last accessed December 2, 2020.

3. Centers for Disease Control and Prevention. Hospital Utilization (in Non-Federal Short-Stay Hospitals). Available at https://www.cdc.gov/nchs/fastats/hospital.htm. Last accessed December 3, 2020.

4. Centers for Disease Control and Prevention. National Center for Health Statistics. National Hospital Discharge Survey. Procedures by Selected Patient Characteristics: Number by Procedure Category and Sex: 2010. Available at https://www.cdc.gov/nchs/nhds/nhds_tables.htm#procedures. Last accessed December 3, 2020.

5. Thompson JS, Baxter BT, Allison JG, Johnson FE, Lee KK, Park WY. Temporal patterns of postoperative complications. Arch Surg. 2003;138(6):596-602.

6. Jefferies S, Weatherall M, Young P, Beasley R. A systematic review of the accuracy of peripheral thermometry in estimating core temperatures among febrile critically ill patients. Crit Care Resusc. 2011;13(3):194-199.

7. Pessaux P, Msika S, Atalla D, Hay JM, Flamant Y, French Associations for Surgical Research. Risk factors for postoperative infectious complications in noncolorectal abdominal surgery: a multivariate analysis based on a prospective multicenter study of 4718 patients. Arch Surg. 2003;138:314-324.

8. Barclay L. Pulmonary Complications of Major Abdominal Surgery May Be Increasing in the US. Available at https://www.medscape.com/viewarticle/557529. Last accessed December 7, 2020.

9. Bottai V, Dell'Osso G, Celli F, et al. Total hip replacement in osteoarthritis: the role of bone metabolism and its complications. Clin Cases Miner Bone Metab. 2015;12(3):247-250.

10. Bagaria V, Modi N, Panghate A, Vaidya S. Incidence and risk factors for development of venous thromboembolism in Indian patients undergoing major orthopaedic surgery: results of a prospective study. Postgrad Med J. 2006;82:136-139.

11. Deitelzweig SB, McKean SC, Amin AN, Brotman DJ, Jaffer AK, Spyropoulos AC. Prevention of venous thromboembolism in the orthopedic surgery patient. Cleve Clin J Med. 2008;75(suppl 3):S27.

12. Berghella V, Baxter JK, Chauhan SP. Evidence-based surgery for cesarean delivery. Am J Obstet Gynecol. 2005;193(5):1607-1617.

13. American Society of PeriAnesthesia Nurses. ASPAN's evidence-based clinical practice guideline for the prevention and/or management of PONV/PDNV. J Perianesth Nurs. 2006;21(4):230-250.

14. Gan TJ, Diemunsch P, Habib AS, et al. Consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg. 2014;118:85-113.

15. Gan TJ, Meyer TA, Apfel CC, et al. Society for Ambulatory Anesthesia guidelines for the management of postoperative nausea and vomiting. Anesth Analg. 2007;105:1615-1628.

16. Lexicomp Online. Available at https://online.lexi.com. Last accessed December 11, 2020.

17. White PF. Prevention of postoperative nausea and vomiting—a multimodal solution to a persistent problem. N Engl J Med. 2004;350(24):2511-2512.

18. Lee A, Done ML. Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting. Cochrane Database Syst Rev. 2004;3:CD003281.

19. Lee A, Fan LT. Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting. Cochrane Database Syst Rev. 2009;15(2):CD003281.

20. Vutyavanich T, Kraisarin T, Ruangsri R. Ginger for nausea and vomiting in pregnancy: randomized, double-masked, placebo-controlled trial. Obstet Gynecol. 2001;97(4):577-582.

21. National Center for Complementary and Integrative Health. Lavender. Available at https://www.nccih.nih.gov/health/lavender. Last accessed December 11, 2020.

22. Mamaril ME, Windle PE, Burkard JF. Prevention and management of postoperative nausea and vomiting: a look at complementary techniques. J Perianesth Nurs. 2006;21(6):404-410.

23. Hodge NS, McCarthy MS, Pierce RM. A prospective randomized study of the effectiveness of aromatherapy for relief of postoperative nausea and vomiting. J Perianesth Nurs. 2014;29(1):5-11.

24. Malignant Hyperthermia Association of the United States. What is MH? Available at https://www.mhaus.org/faqs/. Last accessed December 12, 2020.

25. Chapin JW. Malignant Hyperthermia Workup. Available at https://emedicine.medscape.com/article/2231150-workup. Last accessed December 12, 2020.

26. Ali SZ, Taguchi A, Rosenberg H. Malignant hyperthermia. Best Pract Res Clin Anaesthesiol. 2003;17(4):519-533.

27. Rosenberg H. Malignant Hyperthermia Syndrome. Available at https://www.mhaus.org/healthcare-professionals/professional-development/presentations/malignant-hyperthermia-syndrome/#:~:text=Henry%20Rosenberg%2C%20M.D.&text=An%20inherited%20disorder%20of%20skeletal,hyperthermia%2C%20and%20death%20if%20untreated.. Last accessed December 20, 2020.

28. Gomez MA, Canseco HC, Tovar BD, et al. Postoperative hypothermia: role of the nurses' aide in ensuring the patient's well-being and comfort. Enferm Clin. 2009;19(1):48-51.

29. Karalapillai D, Story D, Hart GK, et al. Postoperative hypothermia and patient outcomes after elective cardiac surgery. Anaesthesia. 2011;66(9):780-784.

30. American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiol. 2004;100(6):1573-1581.

31. Tie HT, Su GZ, He K, Liang SR, Yuan HW, Mou JH. Efficacy and safety of ondansetron in preventing postanesthesia shivering: a meta-analysis of randomized controlled trials. BMC Anesthesiol. 2014;14:12.

32. Geriatrics and Extended Care Strategic Healthcare Group: National Pain Management Coordinating Committee. Pain as the 5th Vital Sign Toolkit. Washington, DC: Veterans Health Administration; 2000.

33. American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiol. 2012;116(2):248-273.

34. Dahl JB, Nielsen RV, Wetterslev J, et al. Post-operative analgesic effects of paracetamol, NSAIDs, glucocorticoids, gabapentinoids and their combinations: a topical review. Acta Anesthesiol Scand. 2014;58(10):1165-1181.

35. Wick EC, Grant MC, Wu CL. Postoperative multimodal analgesia pain management with nonopioid analgesics and techniques: a review. JAMA Surg. 2017;152(7):691-697.

36. Tan M, Law LS, Gan TJ. Optimizing pain management to facilitate Enhanced Recovery After Surgery pathways. Can J Anaesth. 2015;62(2):203-218.

37. Stanford Health Care. General Surgery: Postoperative Complications. Available at https://stanfordhealthcare.org/medical-clinics/surgery-clinic/what-to-expect/complications.html. Last accessed December 12, 2020.

38. Conde MV, Adams SG. Overview of the Management of Postoperative Pulmonary Complications. Available at https://www.uptodate.com/contents/overview-of-the-management-of-postoperative-pulmonary-complications. Last accessed December 12, 2020.

39. Osborne S, Gardner G, Gardner A, Franklin S, Tuohy E, Fisher A. Using a monitored sip test to assess risk of aspiration in postoperative patients. AORN J. 2006;83(4):908-928.

40. American Society of Anesthesiologists Committee on Standards and Practice Parameters. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiol. 2017;126(3):376-393.

41. American Society of Anesthesiologists Committee on Standards and Practice Parameters. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures. Anesthesiol. 2011;114(3):495-511.

42. Ead H. Review of laryngospasm and noncardiogenic pulmonary edema. Dynamics. 2003;14(3):9-12.

43. Boshkov LK. Transfusion-related acute lung injury and the ICU. Crit Care Clin. 2005;21(3):479-495.

44. Benjamin RJ. Tracking TRALI in target populations. Blood. 2011;117(16):4163-4164.

45. Graesdal A, Aagnes I, Lappegard KT. Postoperative cardiovascular complications. Tidsskr nor Laegeforen. 2005;125(21):2942-2945.

46. Centers for Disease Control and Prevention. High Blood Pressure Facts. Available at https://www.cdc.gov/bloodpressure/facts.htm. Last accessed December 13, 2020.

47. Haas CE, LeBlanc JM. Acute postoperative hypertension: a review of therapeutic options. Am J Health-Syst Pharm. 2004;61(16):1661-1673.

48. Walsh ST, Tang T, Wijewardena C, Yarham SI, Boyle JR, Gaunt ME. Postoperative arrhythmias in general surgical patients. Ann R Coll Surg Engl. 2007;89(2):91-95.

49. National Heart, Lung, and Blood Institute. Venous Thromboembolism. Available at https://www.nhlbi.nih.gov/health-topics/venous-thromboembolism. Last accessed December 13, 2020.

50. Guyatt GH, Aki EA, Crowther M, Schunermann HJ, Gutterman DD, Lewis SZ. Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141 (2 Suppl):48S-52S.

51. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines (8th ed). Chest. 2008;133(6 suppl):381S-453S.

52. Radhakrishnan J, Jesudasan S, Jacob R. Delayed awakening or emergence from anaesthesia. Physiology. 2001;13(3):1-2.

53. Burns SM. Delirium during emergence from anesthesia: a case study. Crit Care Nurse. 2003;23(1):66-69.

54. Hudek K. Emergence delirium: a nursing perspective. AORN J. 2009;89(3):509-516.

55. Radtke FM, Franck M, Hagemann L, Seeling M, Wernecke KD, Spies CD. Risk factors for inadequate emergence after anesthesia: emergence delirium and hypoactive emergence. Minerva Anesthesiol. 2010;76(6):394-403.

56. Lepouse C, Lautner CA, Liu L, Gomis P, Leon A. Emergence delirium in adults in the post-anaesthesia care unit. Br J Anaesth. 2006;96(6):747-753.

57. Brull SJ, Kopman AF. Current status of neuromuscular reversal and monitoring: challenges and opportunities. Anesthesiology. 2017;126:173-190.

58. Strauss PZ, Lewis MM. Identifying and treating postanesthesia emergencies. OR Nurse. 2015;9:24-30.

59. McGrath CD, Hunter JM. Monitoring of neuromuscular block. Anaesth Crit Care. 2006;6(1):7-12.

60. GD Shorten, Merk H, Sieber T. Perioperative train-of-four monitoring and residual curarization. Can J Anaesth. 1995;42(8):711-715.

61. Playfor S, Jenkins I, Boyles C, et al. United Kingdom Paediatric Intensive Care Society Sedation, Analgesia and Neuromuscular Blockade Working Group consensus guidelines for sustained neuromuscular blockade in critically ill children. Paediatr Anaesth. 2007;17:881-887.

62. Seiler JG, Casey PJ, Haas Binford S. Compartment syndromes of the upper extremity. J S Orthop Assoc. 2009;9(4).

63. Rasul AT, Jr. Acute Compartment Syndrome. Available at https://emedicine.medscape.com/article/307668-overview. Last accessed December 14, 2020.

64. Golembiewski J, Chernin E, Chopra T. Prevention and treatment of postoperative nausea and vomiting. Am J Health-Syst Pharm. 2005;62(12):1247-1260.

65. Maharaj CH, Kallam SR, Malik A, Hassett P, Grady D, Laffey JG. Preoperative intravenous fluid therapy decreases postoperative nausea and pain in high risk patients. Anesth Analg. 2005;100(3):675-682.

66. Hahn RG. Fluid absorption in endoscopic surgery. BJA. 2006;96(1):8-20.

67. Chambers A. Transurethral resection syndrome—it does not have to be a mystery. AORN. 2002;75(1):156-164.

68. Cagir B. Postoperative Ileus. Available at https://emedicine.medscape.com/article/178948-overview. Last accessed December 14, 2020.

69. Waldhausen JH, Schirmer BD. The effect of ambulation on recovery from postoperative ileus. Ann Surg. 1990;212(6):671-677.

70. Gannon RH. Current strategies for preventing or ameliorating postoperative ileus: nasogastric tube removal. Am J Health-Syst Pharm. 2007;64(20):S8-S12.

71. Abelha FJ, Botelho M, Fernandes V, Barros H. Determinants of postoperative acute kidney injury. Crit Care. 2009;13(3):R79.

72. Needham E. Management of acute renal failure. Am Fam Physician. 2005;72(9):1739-1746.

73. Kheterpal S, Tremper KK, Englesbe MJ, et al. Predictors of postoperative acute renal failure after noncardiac surgery in patients with previously normal renal function. Anesthesiol. 2007;107(6):892-902.

74. Singri N, Ahya SN, Levin ML. Acute renal failure. JAMA. 2003;289:747-751.

75. Workeneh BT. Acute Kidney Injury. Available at https://emedicine.medscape.com/article/243492-overview. Last accessed December 14, 2020.

76. Cassey JG, King RA, Armstrong P. Is there thermal benefit from preoperative warming in children? Paediatr Anaesth. 2010;20(1): 63-71.

77. Ireland D. Unique concerns of the pediatric surgical patient: pre-, intra-, and postoperatively. Nurs Clin North Am. 2006;41(2): 265-298.

78. Ray M, Saha E. Complications following general anaesthesia in paediatric patients. Indian J Anaesth. 2004;48(5):400-405.

79. U.S Census Bureau. A Wave of Change. Available at https://www.census.gov/library/visualizations/2020/comm/a-wave-of-change.html. Last accessed December 14, 2020.

80. American Academy of Health and Fitness. Senior Fitness: Aging and the 11 Body Systems. Available at https://aahf.info/senior-fitness-aging-and-the-body-systems/. Last accessed December 14, 2020.

81. Liu LL, Leung JM. Predicting adverse postoperative outcomes in patients aged 80 years or older. J Am Geriatr Soc. 2000;48(4): 405-412.

82. Barnett SR. Geriatric education: "start low, go slow." ASA Newsletter. 2004;68(5).

83. Sawyer P, Bodner EV, Ritchie CS, Allman RM. Pain and pain medication use in community-dwelling older adults. Am J Geriatr Pharmacother. 2006;4(4):316-324.

84. Mamaril ME. Nursing considerations in the geriatric surgical patient: the perioperative continuum of care. Nurs Clin North Am. 2006;41(2):313-328.

85. National Alliance of Healthcare Purchaser Coalitions. Action Brief: Bariatric Surgery. Available at https://the-alliance.org/wp-content/uploads/2019/08/NA_Action-Brief_BARIATRIC_Branded-TheAlliance.pdf. Last accessed December 14, 2020.

86. Hamdy O. Obesity. Available at https://emedicine.medscape.com/article/123702-overview. Last accessed December 14, 2020.

87. DeMaria EJ. Bariatric surgery for morbid obesity. N Engl J Med. 2007;356(21):2176-2183.

88. Schauer PR, Mingrone G, Ikramuddin S, Wolfe B. Clinical outcomes of metabolic surgery: efficacy of glycemic control, weight loss, and remission of diabetes. Diabetes Care. 2016;39(6):902-911.

89. Owens TM. Bariatric surgery risks, benefits, and care of the morbidly obese. Nurs Clin North Am. 2006;41(2):249-263.

90. Elder KA, Wolfe BM. Bariatric surgery: a review of procedures and outcomes. Gastroenterol. 2007;132(6):2253-2271.

91. Dimick JB, Chen SL, Taheri PA, Henderson WG, Khuri SF, Campbell DA Jr. Hospital costs associated with surgical complications: a report from the private-sector National Surgical Quality Improvement Program. J Am Coll Surg. 2004;199(4):531-537.

92. Singh JA, Yu S, Chen L, Cleveland JD. Rates of Total Joint Replacement in the United States: Future Projections to 2020–2040 Using the National Inpatient Sample. Available at https://www.jrheum.org/content/jrheum/early/2019/04/09/jrheum.170990.full.pdf. Last accessed December 2, 2020.

93. Centers for Disease Control and Prevention. Overweight and Obesity. Available at https://www.cdc.gov/obesity/adult/defining.html. Last accessed December 14, 2020.

94. American Society for Metabolic and Bariatric Surgery. Bariatric Surgery Procedures. Available at https://asmbs.org/patients/bariatric-surgery-procedures. Last accessed December 14, 2020.

Evidence-Based Practice Recommendations Citations

1. Apfelbaum JL, Task Force on Postanesthetic Care. Practice guidelines for postanesthetic care: an updated report by the American Society of Anesthesiologists Task Force on Postanesthetic Care. Anesthesiology. 2013;118(2):291-307. Available at https://pubs.asahq.org/anesthesiology/article/118/2/291/13600/Practice-Guidelines-for-Postanesthetic-CareAn. Last accessed January 8, 2021.

2. National Clinical Guideline Centre for Acute and Chronic Conditions. Venous Thromboembolism in Adults Admitted to Hospital: Reducing the Risk. London: National Institute for Health and Care Excellence; 2015. Available at https://www.acutemedicine.org.uk/wp-content/uploads/2015/12/NICE-Reducing-VTE-201015.pdf. Last accessed January 8, 2021.

3. American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults. American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults. J Am Geriatr Soc. 2015;63(1):142-150. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5901697. Last accessed January 10, 2018.

4. Murray MJ, DeBlock H, Erstad B, et al. Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Crit Care Med. 2016;44(11):2079-2103. Available at https://journals.lww.com/ccmjournal/Fulltext/2016/11000/Clinical_Practice_Guidelines_for_Sustained.16.aspx. Last accessed January 8, 2021.

5. Mechanick JI, Youdim A, Jones DB, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic and Bariatric Surgery. Endocr Pract. 2013;19(2):337-372. Available at https://asmbs.org/app/uploads/2014/05/AACE_TOS_ASMBS_Clinical_Practice_Guidlines_3.2013.pdf. Last accessed January 8, 2021.