POST ANAESTHESIA CARE UNIT (PACU) DR.SHAILENDRA.V.L. SPECIALIST IN ANAESTHESIA . AL BUKARIYA GENERAL HOSPITAL .

Introduction Importance of PACU Adequate preparedness Sudden complication

Importance of PACU

Adequate preparedness

Sudden complication

History of PACU 1947: Anaesthesia Study Commission report Experience of trauma management in 2nd World War Advances in Surgery in 50’s and 60’s Day care surgery concept of the 90s

1947: Anaesthesia Study Commission report

Experience of trauma management in 2nd World War

Advances in Surgery in 50’s and 60’s

Day care surgery concept of the 90s

Design of PACU Location: Close to Operating Rooms Easy access to Lab, X-ray, Blood bank Close to ICU Size: Ideal 1.5 PACU bed for every OR 120 square foot per patient Minimum of 7 feet between beds

Location:

Close to Operating Rooms

Easy access to Lab, X-ray, Blood bank

Close to ICU

Size:

Ideal 1.5 PACU bed for every OR

120 square foot per patient

Minimum of 7 feet between beds

Design of PACU Facilities: Fowler’s cot with side rails Piped Oxygen, Vacuum and Air Multiple electrical outlets Large doors Good lighting Isolation for Immuno-compromised patients

Facilities:

Fowler’s cot with side rails

Piped Oxygen, Vacuum and Air

Multiple electrical outlets

Large doors

Good lighting

Isolation for Immuno-compromised patients

Equipments in PACU Tray with labeled Emergency drugs Airway maintenance kit: Laryngoscope with all size blades All sizes Endotracheal tubes Face masks, Airways, Ambu Bag, Venturi masks Tracheostomy set ICD set Transport ventilator

Tray with labeled Emergency drugs

Airway maintenance kit:

Laryngoscope with all size blades

All sizes Endotracheal tubes

Face masks, Airways, Ambu Bag, Venturi masks

Tracheostomy set

ICD set

Transport ventilator

Equipments in PACU Personnel: Requirement varies 1 : 1 ratio good 1 : 3 ratio acceptable for busy OR’s Monitors: ECG Pulse oximeter Non invasive BP EtCO 2 Invasive pressure monitor Temperature

Personnel:

Requirement varies

1 : 1 ratio good

1 : 3 ratio acceptable for busy OR’s

Monitors:

ECG

Pulse oximeter

Non invasive BP

EtCO 2

Invasive pressure monitor

Temperature

Routine Post-Anaesthesia Care Criteria for shifting from OR---to---PACU Conscious, awake, responds to simple commands Haemo dynamic stability Clinical evaluation for NM blockade recovery Maintainance of Oxygen Saturation Normothermia

Criteria for shifting from OR---to---PACU

Conscious, awake, responds to simple commands

Haemo dynamic stability

Clinical evaluation for NM blockade recovery

Maintainance of Oxygen Saturation

Normothermia

Transportation to PACU Fowler’s cot with side rails Patient handed over to PACU nurse by the Anaesthesiologist

Fowler’s cot with side rails

Patient handed over to PACU nurse by the Anaesthesiologist

Care in PACU Monitoring : ECG, SpO 2 , Blood pressure Oxygen therapy Pain therapy, anti-emetics Blood Pressure recording: Every 5 minutes for 30 minutes Every 15 minutes for next 30 minutes

Monitoring : ECG, SpO 2 , Blood pressure

Oxygen therapy

Pain therapy, anti-emetics

Blood Pressure recording:

Every 5 minutes for 30 minutes

Every 15 minutes for next 30 minutes

Post Operative Complications Respiratory Complications: Airway obstruction Hypoxemia Increased Left to Right shunt

Respiratory Complications:

Airway obstruction

Hypoxemia

Increased Left to Right shunt

Post Operative Complications Airway Obstruction: Sagging tongue: Treated with triple maneuver Laryngeal Spasm: Due to secretions Due to irritable airways (smokers) Rx: 100% Oxygen through face mask Hydrocoritsone 100 mg IV If no improvement rapid intubation to secure the airway

Airway Obstruction:

Sagging tongue: Treated with triple maneuver

Laryngeal Spasm:

Due to secretions

Due to irritable airways (smokers)

Rx: 100% Oxygen through face mask

Hydrocoritsone 100 mg IV

If no improvement rapid intubation to secure the airway

Post operative Complications Hypoxemia: Low FIO 2 : Diffusion hypoxemia (N 2 O 31 times more soluble than O 2 ) Hypoventilation: Inadequate N.M. blockade recovery Respiratory depressant effect of volatile agents, narcotics, benzodiazepines Hypocarbia intra operatively Upper abdominal incisions

Hypoxemia:

Low FIO 2 :

Diffusion hypoxemia (N 2 O 31 times more soluble than O 2 )

Hypoventilation:

Inadequate N.M. blockade recovery

Respiratory depressant effect of volatile agents, narcotics, benzodiazepines

Hypocarbia intra operatively

Upper abdominal incisions

Post operative Complications Increased Right to Left Shunt: Atelectasis: Inadvertent endobroncial intubation Ateclectasis of the lung Increased Shunt ( R to L ) Blockage of Brochus by blood or mucous plug Pnemothorax: following rib injury following CVP placement

Increased Right to Left Shunt:

Atelectasis:

Inadvertent endobroncial intubation

Ateclectasis of the lung

Increased Shunt ( R to L )

Blockage of Brochus by blood or mucous plug

Pnemothorax:

following rib injury

following CVP placement

Post operative Complications Circulatory Complications: Hypotension: Decreased preload Decreased myocardial contractility Increased after load

Circulatory Complications:

Hypotension:

Decreased preload

Decreased myocardial contractility

Increased after load

Post operative Complications Decreased preload: Increased blood loss Increased III space loss Un diagnosed urinary loss Septicemia Decreased myocardial contractility: Depressant effect of GA drugs Pre-existing ventricular dysfunction Per operative Myocardial infarction Decreased After load: Volatile agents depression Septic shock Profound decreased SVR Septic shock Volatile agents effects

Decreased preload:

Increased blood loss

Increased III space loss

Un diagnosed urinary loss

Septicemia

Decreased myocardial contractility:

Depressant effect of GA drugs

Pre-existing ventricular dysfunction

Per operative Myocardial infarction

Decreased After load:

Volatile agents depression

Septic shock

Profound decreased SVR

Septic shock

Volatile agents effects

Post operative Complications Hypertension: Pain Hypercapnia Hypothermia Hypoxemia Excess Intra vascular volume Pre-existing hypertension

Hypertension:

Pain

Hypercapnia

Hypothermia

Hypoxemia

Excess Intra vascular volume

Pre-existing hypertension

Post operative Complications Arrythmias: Electrolyte imbalance ( K ) Hypoxia Hypercarbia Metabolic acidosis

Arrythmias:

Electrolyte imbalance ( K )

Hypoxia

Hypercarbia

Metabolic acidosis

Post operative Complications Post-operative pain & agitation: Ascertain adequacy of Blood-Gas exchange Evaluate for any gastric or urinary distension Rx: small doses of narcotics.

Post-operative pain & agitation:

Ascertain adequacy of Blood-Gas exchange

Evaluate for any gastric or urinary distension

Rx: small doses of narcotics.

Post operative Complications Nausea & Vomiting: Frequently seen after lapraroscopic surgeries Strabismus surgeries Rx with Ondansetron 4mg IV adults / child 0.1mg/kg Metoclopromide 0.15mg/kg IV

Nausea & Vomiting:

Frequently seen after

lapraroscopic surgeries

Strabismus surgeries

Rx with Ondansetron 4mg IV adults / child 0.1mg/kg

Metoclopromide 0.15mg/kg IV

Post operative Complications Hypothermia & shivering: Air-conditioning : excessive cooling Cold IV fluids transfused Cold irrigating fluids used by the surgeon Halothane anaesthesia Rx by warm blankets Warm IV fluids Inj. Pethidine 10mg IV

Hypothermia & shivering:

Air-conditioning : excessive cooling

Cold IV fluids transfused

Cold irrigating fluids used by the surgeon

Halothane anaesthesia

Rx by warm blankets

Warm IV fluids

Inj. Pethidine 10mg IV

Discharge criteria from PACU “ Neither an arbitrary time limit nor a discharge score can be used to define a medically appropriate length stay in the recovery room accurately ”

“ Neither an arbitrary time limit nor a discharge score can be used to define a medically appropriate length stay in the recovery room accurately ”

Discharge criteria from PACU All patients must be evaluated by anesthesiologist prior to discharge from PACU Criteria for discharge developed by the Anesthesia department Criteria depends on where the patient is sent – ward, ICU, home

All patients must be evaluated by anesthesiologist prior to discharge from PACU

Criteria for discharge developed by the Anesthesia department

Criteria depends on where the patient is sent – ward, ICU, home

Discharge criteria from PACU Easy arousability Full orientation Ability to maintain & protect airway Stable vital signs for at least 15 – 30 minutes The ability to call for help if necessary No obvious surgical complication (active bleeding)

Easy arousability

Full orientation

Ability to maintain & protect airway

Stable vital signs for at least 15 – 30 minutes

The ability to call for help if necessary

No obvious surgical complication (active bleeding)

Post-anesthetic Aldrete recovery score

Interpretation of Modified Aldrete’s score Lowest score = 0 – 2 Score for patient to be shifted to next level of care = 0 to 8 Since some patients on arrival to PACU will meet the score of 8, it is very illogical to fix a number for shifting the patient Ideally it should be decision of the Anesthesiologist regarding the shifting from the PACU to next level of care taking into account the anesthetic plan & the drugs given intra-operatively as well as in PACU

Lowest score = 0 – 2

Score for patient to be shifted to next level of care = 0 to 8

Since some patients on arrival to PACU will meet the score of 8, it is very illogical to fix a number for shifting the patient

Ideally it should be decision of the Anesthesiologist regarding the shifting from the PACU to next level of care taking into account the anesthetic plan & the drugs given intra-operatively as well as in PACU

Post-anesthesia discharge scoring system

Safe guidelines for discharging home after ambulatory surgery Patient should be able to stand & take a few steps ( sit on bed if C/ I for standing) Should be able to sip fluids Should be able to urinate Should be able to repeat post-operative management Should be able to identify the escort (cognitive function)

Patient should be able to stand & take a few steps ( sit on bed if C/ I for standing)

Should be able to sip fluids

Should be able to urinate

Should be able to repeat post-operative management

Should be able to identify the escort (cognitive function)

Thank you