CAPA Perianesthesia Complications & Emergency Response 2 — Questions and Answers
Question 1: A patient develops urticaria, hypotension, and wheezing minutes after receiving IV antibiotics in the PACU. What is the FIRST-LINE treatment?
- Diphenhydramine 50 mg IV
- Methylprednisolone 125 mg IV
- Epinephrine 0.3 mg IM into the anterolateral thigh (Correct answer)
- Albuterol via nebulizer
Correct answer: Epinephrine 0.3 mg IM into the anterolateral thigh
Epinephrine is the first-line treatment for anaphylaxis, addressing vasodilation, bronchoconstriction, and angioedema through alpha and beta adrenergic receptor activation.
Question 2: Local anesthetic systemic toxicity (LAST) most characteristically presents initially with which symptom cluster?
- Cardiovascular collapse and pulseless VT
- CNS excitation: perioral numbness, tinnitus, and metallic taste (Correct answer)
- Respiratory arrest without warning
- Severe hypotension and bradycardia
Correct answer: CNS excitation: perioral numbness, tinnitus, and metallic taste
LAST progresses in a predictable sequence with CNS excitation symptoms — perioral numbness, tinnitus, metallic taste, restlessness — preceding cardiovascular toxicity.
Question 3: What is the definitive treatment for refractory cardiac arrest caused by local anesthetic systemic toxicity (LAST)?
- High-dose epinephrine bolus (>1 mg IV)
- 20% lipid emulsion (intralipid) IV bolus (Correct answer)
- Calcium chloride 1 g IV
- Sodium bicarbonate 1 mEq/kg IV
Correct answer: 20% lipid emulsion (intralipid) IV bolus
20% lipid emulsion acts as a 'lipid sink,' sequestering lipophilic local anesthetic from cardiac tissue, and is the definitive ASRA-recommended treatment for LAST cardiac arrest.
Question 4: What is the correct initial bolus dose of 20% lipid emulsion (intralipid) for LAST per ASRA guidelines?
- 0.5 mL/kg IV over 2-3 minutes
- 1 mL/kg IV over 2-3 minutes
- 1.5 mL/kg IV over 2-3 minutes (Correct answer)
- 2 mL/kg IV over 2-3 minutes
Correct answer: 1.5 mL/kg IV over 2-3 minutes
ASRA guidelines recommend 1.5 mL/kg of 20% lipid emulsion as an IV bolus over 2-3 minutes, followed by a continuous infusion of 0.25 mL/kg/min.
Question 5: Which patient factor MOST significantly increases the risk of pulmonary aspiration in the perianesthesia period?
- Age greater than 65 years
- History of GERD combined with inadequate preoperative fasting (Correct answer)
- Use of regional anesthesia technique
- Female sex and obesity combined
Correct answer: History of GERD combined with inadequate preoperative fasting
GERD increases gastric acid presence and inadequate fasting increases gastric volume, together significantly elevating the risk of regurgitation and aspiration.
Question 6: After administering epinephrine for anaphylaxis, what is the NEXT priority intervention?
- Administer diphenhydramine 50 mg IV
- Establish large-bore IV access and begin aggressive fluid resuscitation (Correct answer)
- Obtain a 12-lead ECG immediately
- Apply high-flow oxygen via non-rebreather mask only
Correct answer: Establish large-bore IV access and begin aggressive fluid resuscitation
Following epinephrine, large-bore IV access and fluid resuscitation are critical to counteract the vasodilation and relative hypovolemia that characterize severe anaphylaxis.
Question 7: A PACU patient who received a bupivacaine femoral nerve block develops sudden seizures and progressive QRS widening on the monitor. The nurse should FIRST:
- Administer phenytoin IV for seizure control
- Call for the MH cart and begin cooling measures
- Activate the LAST protocol and prepare 20% lipid emulsion (Correct answer)
- Administer amiodarone IV for the wide-complex rhythm
Correct answer: Activate the LAST protocol and prepare 20% lipid emulsion
Sudden seizures followed by cardiac conduction abnormalities in a patient who received a bupivacaine block are classic LAST presentation, requiring immediate LAST protocol activation including intralipid.
CAPA Perianesthesia Complications & Emergency Response 2
A patient develops urticaria, hypotension, and wheezing minutes after receiving IV antibiotics in the PACU.
What is the FIRST-LINE treatment?