When to Contact Anesthesia

Sirrahsim · Oct 4, 2022

The patient spent several more hours in the PACU before being transferred to the floor in stable condition. So yes, it ended up being just fine to wait and see in this situation.

Thank you all for your input. I am working hard to fine tune my PACU skills and transition from ICU where we work as a team to PACU where contradicting anesthesia is like questioning the Pope.

subee, MSN, CRNA · Oct 10, 2022

On 10/4/2022 at 7:42 PM, Sirrahsim said:

The patient spent several more hours in the PACU before being transferred to the floor in stable condition. So yes, it ended up being just fine to wait and see in this situation.

Thank you all for your input. I am working hard to fine tune my PACU skills and transition from ICU where we work as a team to PACU where contradicting anesthesia is like questioning the Pope.

PACU time is expensive. Time is money. This patient spent several extra hours in the PACU and that costs someone a lot of money. This patient was difficult to arouse and had an extremely slow respiratory rate for over 90 minutes. That's not the way we are supposed to drop them off to PACU. An experienced and capable provider would rather not deliver a product of poor judgement to the PACU.

BlueShoes12, BSN, RN · Nov 12, 2022

On 9/30/2022 at 12:01 AM, Sirrahsim said:

I am an ICU nurse who left the world of ICU and started in the PACU recently. The training was very much focused on unit specific charting and did not cover when I should report abnormal findings to anesthesia. Recently one of the anesthesiologists was laughing about a nurse (not knowing it was me) who had contacted anesthesia repeatedly related to a prolonged and continuous respiratory rate of 5 and 6. They stated "that's what PACU is for"

That brings me to the question. What parameters are appropriate to contact anesthesia for?

In the ICU I would absolutely report respiratory depression, especially if persistent and with no way to monitor ETCO2. In this case the patient was extremely somnolent and would only respond for a few seconds to physical stimuli. I contacted anesthesia 3 times at 30 minute intervals to request a small dose of narcan and was told to just keep watching because "giving narcan is so mean"

This same provider has also ridiculed me for contacting them after a patient with a baseline heart rate of 70 suddenly started dropping down to a heart rate of 40 after being stable for an hour after reversal with neostigmine/glycopyrolate.

Are these things normal findings in PACU that I just need to monitor as they suggest? Its unfathomable to me to think of NOT reporting these findings.

You present a couple of very interesting scenarios! In the first case, I wouldn't get too excited if that patient remained that way for 30 or 40 minutes post-op. If it persisted after that, I would follow up with the anesthesiologist like you did. I've had one patient much like what you describe, except that they wouldn't even arouse to stimuli (including a very aggressive sternal rub). After about an hour, the anesthesiologist had me give small doses of Narcan (0.04 mg (0.4 mg/1 mL of Narcan diluted with 9mL saline) q 5 minutes. After 3 doses, the patient started to become arousable, although still very drowsy. We stopped there, and then the patient gradually became more alert over the next hour or so without putting them straight into screaming pain. In my PACU, the nurse can also initiate etCO2 monitoring if we think it is necessary. I would have done so in your patient's case so that you could provide that information to the anesthesiologist.

Regarding your other patient with bradycardia, I also had a similar scenario the other day. The patient had a pre-op heart rate of NSR in the low 60s and, about an hour after their outpatient surgery, started dropping as low as 39 (sinus brady). They were otherwise hemodynamically and completely asymptomatic. Upon reviewing the anesthesia record, I noticed that they had received glycopyrrolate/Robinul approximately an hour before for bradycardia near the end of the case. I contacted the anesthesiologist and they instructed me to administer 0.2 mg of glycopyrrolate. The patient's heart rate increased to the high 50s. About an hour later, the patient's heart rate began dropping to the high 40s again; the patient remained asymptomatic. I updated the anesthesiologist, who stated the patient was OK to discharge, and I sent them home in stable condition with that heart rate.

I'm lucky enough to work with wonderful anesthesia providers (both CRNAs and anesthesiologists), but before contacting them, I always make sure that I have done my homework and have all of the information that I need to present my case to them. If you aren't sure, you can always run the scenario by your charge nurse before calling, too.