principle of post anesthesia care

1. Post anesthesia care Unit
(PACU)
Amanuel Sisay (MSc)
1

2. Course objectives (1/4)
• Explain techniques of postoperative patient’s
transportation.
• Recognize methods of handover for postoperative
patients.
• Recognize recovery and other positions in the PACU.
• Describe the required equipment’s and monitoring in the
PACU.
• Explore patient follow up strategies in the PACU.
• Analyze monitoring parameters in the PACU.
• Identify common postoperative complications in PACU.
• Discussed adverse outcomes of untreated postoperative
pain
2

3. Course objectives (2/4)
• Explore different modalities of postoperative pain
management.
• Describe adverse effects of different analgesics.
• Recognize the impact of PONV
• Describe the factors that predispose to PONV
• Describes prevention, treatment the basic pharmacology of
anti-emetic drugs .
• Identify possible causes of hypoxia and hypoventilation
• Describes how to evaluate neuro-muscular blocker with the
nerve stimulator.
• Identify management of laryngospasm and other complications
of extubation
• List indications of oxygen therapy
• Describe techniques of oxygen therapy
3

4. Course objectives (3/4)
• Describes the causes and management of postoperative atelectasis,
tachycardia, bradycardia, arrhythmias, bleeding, hypotension and hypertension.
• Describe mechanisms and management of hypothermia.
• Describes the possible causes and management of postoperative confusion
and cognitive deterioration.
• Identify conditions that need higher level of postoperative care.
• Explain discharge criteria (Modified Aldrete Criteria )from PACU (in-
hospital or home)
• Identify organizational and structural requirements of the PACU
• Identify common critical incidents (Cardiorespiratory arrest) in the PACU
and early warning assessment methods
• Arrange the organization and requirements of safe PACU
• Interpret monitoring parameters and intervene accordingly.
• Evaluates neuromuscular blockade using a nerve stimulator.
4

5. Course objectives (4/4)
• Administer oxygen with different techniques (nasal
prongs, facemasks…)
• Assess postoperative pain.
• Prescribes appropriate postoperative analgesia.
• Prescribes appropriate postoperative fluid regimes
• Manage amenable bleeding and provide resuscitation.
• Prevent, assess and manage hypothermia in the PACU
5

6. Session 1: (Start from tomorrow)
• Organization, staffing and safety of PACU
• Admission and discharge criteria to PACU
• Transportation handover and positioning
• Equipment and monitoring required in the PACU
• Physiology, assessment, management of postoperative
acute pain
6

7. Session 2:
• Mechanisms, impacts, factors, prevention and
management of PONV
• Causes of hypoxia and hypoventilation, oxygen therapy
• Identification prevention and management of other
common postoperative complications (atelectasis,
tachycardia, bradycardia, arrhythmias, bleeding, hypotension,
hypertension, hypothermia, confusion and cognitive
deterioration )
7

8. Session 3:
• Assessment and management of Post anesthesia cognition
and confusion
• Assessment for discharge from PACU (in-hospital and
home)
• Reassuring and helping patients in CRC manner and
develop interdepartmental communication and collaboration
8

9. Methods of Assessment (1/1)
• Formative
• Drills, essay exams,
quizzes, and practical test
(direct observation of skills)
• Structured feedback
report
• Logbook
• Portfolio
• DOP, PCE, CBD
• And other assessment
methods
• Summative
• Progressive/ Continuous
assessment: (10%)
• DOP, PCE, CBD: (15%)
• Written exam (50%)
• Objectively Structured
Clinical Examination (OSCE):
(15%)
9

10. Reference Books
• Paul G Barash: Handbook of Clinical Anesthesia (6th edition).
Lippincott Williams & Wilkins publications, Inc., 2009.
• Paul G Barash: Clinical Anesthesia (7th edition). Lippincott Williams
&Wilkins publications, Inc., 2014.
• Ronald D. Miller: Millers Anesthesia (8th edition). Churchill
Livingstone publication, An Imprint of Elsevier, 2015.
• G. Edward Morgan: Clinical Anesthesiology (5th edition). McGraw-
Hill Companies, Inc., 2006
• Ronald D. Miller: Basics of Anesthesia (7th edition). Saunders, an
imprint of Elsevier Inc. 2011.
• Fleisher: Anesthesia and Uncommon Diseases, (5th edition).
Elsevier Saunders Inc., 2005
• James C. Duke: Duke’s Anesthesia Secretes (5th edition). Saunders, 10

11. Postanesthesia Recovery
• Patients recovering from an anesthetic has circumstances that
require individualized problem-oriented approach.
• Postanesthesia recovery must continue to adapt to meet the
needs of the changing - - perioperative landscape
- advances in technology
- changing surgical techniques
- to respond to improved evidence-based research
11

12. Levels of Postoperative/Postanesthesia
Care
• anesthesia services expand to cover a variety of patient types
• everincreasing areas outside the operating room
• selecting the correct type of recovery is essential
12

13. • many differing anesthesia areas ranging from inpatient
surgery, ambulatory surgery, to off-site procedures
• the level of postoperative care that a patient requires is
determined by:
• the degree of underlying illness, comorbidities, and the duration
• the type of anesthesia and surgery.
13

14. • Phase I recovery would be reserved for more intense recovery
and would require more one-on-one care for staff.
• Phase II recovery should be less intensive and is appropriate
for patients after less invasive procedures requiring less
attention from nursing while recovering.
• If separation of different phases of care is not possible, then
providing the appropriate level of monitoring and coverage to
the degree of postoperative impairment achieves similar
results in a single PACU area.
14

15. Postanesthetic Triage
• Triage should be based on
• clinical condition,
• length/type of procedure and anesthetic,
• the potential for complications that require intervention.
• Arbitrary criteria should not be used for determining the level
of recovery care.
• age,
• ASA classification,
• ambulatory versus
• inpatient versus off-site procedure status
• type of insurance
15

16. • intensive procedures and patients with greater acuity,
bypassing the PACU
• direct admission to intensive care units can reduce demands
on the PACU
• reduce errors with decreased number of hand offs
16

17. Safety in the Postanesthesia Care Unit
• Every PACU should have medical oversight in the form of a
medical director
• Medical director must ensure the PACU environment is as safe
as possible for both patients and staff
• Beyond usual safety policies, maintain staffing and training to
ensure that an appropriate coverage and skill mix is available
to deal with unforeseen crises.
• Incidence of adverse events in the PACU correlates with
nursing workload and staff availability.
• Ideally, all staff should have PACU certification, and staffing
ratios should never fall below acceptable standards 17

18. • The staff is obligated
• to optimize each patient’s privacy and dignity
• to minimize the psychological impact of unpleasant or frightening
events.
• Observance of procedures for handwashing, sterility, and
infection control should be strictly enforced.
• Access to the PACU should be strictly controlled.
• Increasing acceptance of reuniting patients with
family/friends, safety and privacy issues need to be
continually addressed.
18

19. • The PACU environment must also be safe for professionals.
• Air handling should guarantee that personnel are not exposed
to unacceptable levels of trace anesthetic gases (although
trace gas monitoring is not necessary)
• Staff members receive appropriate vaccinations, including
those for hepatitis B, flu, and others required by their
institution.
• Personal protective equipment (PPE) such as
• gloves and eye protection
• Worn to protect both the patient and provider
• Having masks, gowns, and appropriate particulate respiratory
equipment easily accessible is needed for particular cases. 19

20. Routine Post-Anaesthesia Care
Criteria for shifting from
OR---to---PACU
□ Haemo dynamic stability
□ Clinical evaluation and
complete recovery from
NM blockade
□ Maintenance of Oxygen
Saturation
□ Normothermia
<C9ATL

21. -
- , a . j cow.,
Transport of client from OR to RR
r avoid exposure
r avoid rough handling
r avoid hurriedmovement and rapid changes in
position.

22. Admission Report
Preoperative history
Intra-operative factors:
• Procedure
• Type of anesthesia
• Estimated Blood Loss (EBL)
. Urine output
·You seem quieter tonight. Did they
giveyousomething tohelpyourelax?"
Assessment and report of current status
Post-operative instructions

23. PACU
• Vital signs are recorded as often as
necessary but at least every 15 minutes
while the patient is in the unit.

24. PACU
Oxygenation
• pulse oximetry
Ventilation
• Resp Rate, airway patency, capnography
Circulation
• BP, HR, ECG
Level of consciousness

25. • Patient may feel the following up to 24 hours
- Sore throat
- Aching muscles
- General malaise
• Shivering - not uncommon
- Warm cotton blankets applied as necessary
- Warm air blanket may be utilized
- Medication is used for extreme shivering
2')

26. 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 PACU accurately
•All patients must be evaluated by anesthesiologist/trained staff prior to
discharge from PACU
•Criteria for discharge developed by the Anesthesia department
•Criteria depends on where the patient is sent - ward, ICU, home

27. 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)

28. Discharge From the PACU
Standard Aldrete Score:
::i Simple sum of numerical values assigned to
activity, respiration, circulation, consciousness,
and oxygen saturation.
o A score of 9 out of 1O shows readiness for
discharge.
Post-anesthesia Discharge Scoring System:
o Modification of the Aldrete score which also
includes an assessment of pain, N/V, and surgical
bleeding, in addition to vital signs and activity.
□ Also, a score of 9 or 10 shows readiness for
discharge.

29. ALDRETESCORE
Post-AnesthesiaScore
Atotaldischargescoreof8-10isnecessary
Post-AnesthesiaScore
PRE-ANESTHESIAVITALSIGNS/SOURCE TIME ADM1s- 3
0
-45" 1' 2' 3
' • DISCHARGE
SYSTOLIC BP 20% OF PRE-ANESTHETIC LEVEL
CIRCULATION 20-50%
>so
2
1
0
)
CONCIOUSNES
FULLYAWAKE
AROUSABLEONCALLING
2
1
s
NOTRESPONDING 0
WARM, DRY SKIN WI PREPROCEDURAL
COLORING 2
COLOR PALE, DUSKY
, BLOTCHY
, JAUNDICED, OTHER
CYANOTIC
1
0
ABLE TO DEEP BREATHE & COUGH FREELY
RESPIRATION APKEIC
2
DYSPNEA OR LIMITED BREATHING
1
0
CTJVITY
ABLETOMOVE4 EXTREMITIES 2
ABLETOMOVE2EXTREMITIES 1
ABLETOMOVEOEXTREMITIES 0
COM NiJi 3,41,.;a JIM TOTAL so

30. Activity Respiration Circulation Consciousness Oxygen
Saturation
2: Movesall
extremities
2:Brealhs deeply
and coughs
2: BP + 20 mm of
pre-anesthetic
2:Fully awake 2: Spo2> 92%
on room air
voluntarily/ on
command freely.
level
1: Moves2
extremities
1: Dyspneic,
shallow or limited
breathing
1: BP+ 20-50 mm
pre-anesthetic
level
1: Arousable on
calling
1:supplemental
02 require<! to
maintain Spo2
>90%
0: Unable lo
move
extremities
0: Apneic 0: BP + 50 mm of
preanestheic level
0: Not responding O:Spo2 <92% with
02
supplementation
Aldrete Score

31. Interpretation of Aldrete's score
Lowest score = 0 - 2
Score for patient to be shifted to next level of
care= 9
o 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
a 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
2/.J/2mS 3:48:01 PM 52

32. Vital Signs
(BP and
Pulse)
Activity Nausea and
Vomiting
Pain Surgical
Bleeding
2: Within 20% ef
preoperative
2: Steady gait,
no dizziness
2: Minimal: treat
with PO meds
2: Ac:ceptable
controlper the
2: Minimal: no
dressing
baseline patient;
controlled with
changes
required
POmeds
1: 20-40% of
preoperative
1: Requires
assistance
1: Moderate:
treat with IM
1: Not
acceptable to the
1: Moderate: up
to 2 dressing
baseline medications patient; not changes
controlled with
PO medications
0: >40% of
preoperative
baseline
0: Unable to
ambulate
0: Continues:
repeated
treatment
0: Severe: more
than 3 dressing
changes
( @ A T L A S
Post-anesthesia Discharge
Scoring System (PADSS)
S3

33. Discharge from the Post Operative Unit
A patient remains in the post op unit, until
the patient has fully recovered from -...._- _::::..:::..
anesthesia.
Following measures are used to
determine the patient ready for
discharge from post operative unit:
Stable vital signs
Orientation to Person, Place
Time or events
Adequate oxygen saturation level.
Urine out put at least 30ml/hour
Minimal pain.
Adequate respiratory function.
Aldrete score more than ' 9 ' "You'll be glod to know your daughter's
surgery went fineond she's owoke Clndtextlng."
2/.J/21l153:48:01 PM

34. Teaching, Patient Self Care
((9ATLA Expected out comes
Immediate post
operative changes
Written instructions like
Wound care
Activity+dietary
recommendation
Medications
Follow up
2/4/2015 3:48:01 PM ss