The postanesthesia care unit


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The postanesthesia care unit

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The postanesthesia care unit

  1. 1. The Postanesthesia Care Unit Jessica Lovich-Sapola MD
  2. 2. PACU <ul><li>Recovery from anesthesia can range from completely uncomplicated to life-threatening. </li></ul><ul><li>Must be managed by skilled medical and nursing personnel. </li></ul><ul><li>Anesthesiologist plays a key role in optimizing safe recovery from anesthesia. </li></ul>
  3. 3. History of the PACU <ul><li>Methods of anesthesia have been available for more than 160 years, the PACU has only been common for the past 50 years. </li></ul><ul><li>1920’s and 30’s: several PACU’s opened in the US and abroad. </li></ul><ul><li>It was not until after WW II that the number of PACU’s increased significantly. This was do to the shortage of nurses in the US. </li></ul><ul><li>In 1947 a study was released which showed that over an 11 year period, nearly half of the deaths that occurred during the first 24 hours after surgery were preventable. </li></ul><ul><li>1949: having a PACU was considered a standard of care. </li></ul>
  4. 4. PACU Staffing <ul><li>One nurse to one patient for the first 15 minutes of recovery. </li></ul><ul><li>Then one nurse for every two patients. </li></ul><ul><li>The anesthesiologist responsible for the surgical anesthetic remains responsible for managing the patient in the PACU. </li></ul>
  5. 5. PACU Location <ul><li>Should be located close to the operating suite. </li></ul><ul><li>Immediate access to x-ray, blood bank, blood gas and clinical labs. </li></ul><ul><li>Should have 1.5 PACU beds per operating room used. </li></ul><ul><li>An open ward is optimal for patient observation, with at least one isolation room. </li></ul><ul><li>Central nursing station. </li></ul><ul><li>Piped in oxygen, air, and vacuum for suction. </li></ul><ul><li>Requires good ventilation, because the exposure to waste anesthetic gases may be hazardous. National Institute of Occupational Safety (NIOSH) has established recommended exposure limits of 25 ppm for nitrous and 2 ppm for volatile anesthetics. </li></ul>
  6. 6. PACU Equipment <ul><li>Automated BP, pulse ox, EKG, and intravenous supports should be located at each bed. </li></ul><ul><li>Area for charting, bed-side supply storage, suction, and oxygen flow meter at each bed-side. </li></ul><ul><li>Capability for arterial and CVP monitoring. </li></ul><ul><li>Supply of immediately available emergency equipment. Crash cart. Defibrillator. </li></ul>
  7. 7. Admission Report <ul><li>Preoperative history </li></ul><ul><li>Intra-operative factors: </li></ul><ul><ul><li>Procedure </li></ul></ul><ul><ul><li>Type of anesthesia </li></ul></ul><ul><ul><li>EBL </li></ul></ul><ul><ul><li>UO </li></ul></ul><ul><li>Assessment and report of current status </li></ul><ul><li>Post-operative instructions </li></ul>
  8. 8. Postoperative Pain Management <ul><li>Intravenous opioids </li></ul><ul><li>Ketorolac and anti-inflammatory drugs </li></ul><ul><li>Midazolam for anxiety </li></ul><ul><li>Epidural </li></ul><ul><li>Regional analgesic blocks </li></ul><ul><li>PCA and PCEA </li></ul>
  9. 9. Discharge From the PACU <ul><li>Aldrete Score: </li></ul><ul><ul><li>Simple sum of numerical values assigned to activity, respiration, circulation, consciousness, and oxygen saturation. </li></ul></ul><ul><ul><li>A score of 9 out of 10 shows readiness for discharge. </li></ul></ul><ul><li>Postanesthesia Discharge Scoring System: </li></ul><ul><ul><li>Modification of the Aldrete score which also includes an assessment of pain, N/V, and surgical bleeding, in addition to vital signs and activity. </li></ul></ul><ul><ul><li>Also, a score of 9 or 10 shows readiness for discharge. </li></ul></ul>
  10. 10. Aldrete Score 0: Spo2 <92% with O2 supplementation 0: Not responding 0: BP + 50 mm of preanestheic level 0 : Apneic 0: Unable to move extremities 1: Supplemental O2 required to maintain Spo2 >90% 1: Arousable on calling 1: BP + 20-50 mm of preanesthetic level 1: Dyspneic, shallow or limited breathing 1: Moves 2 extremities 2: Spo2 > 92% on room air 2:Fully awake 2: BP + 20 mm of preanesthetic level 2:Breaths deeply and coughs freely . 2: Moves all extremities voluntarily/ on command Oxygen Saturation Consciousness Circulation Respiration Activity
  11. 11. Postanesthesia Discharge Scoring System 0: Severe: more than 3 dressing changes 0: Continues: repeated treatment 0: Unable to ambulate 0: >40% of preoperative baseline 1: Moderate: up to 2 dressing changes 1: Not acceptable to the patient; not controlled with PO medications 1: Moderate: treat with IM medications 1: Requires assistance 1: 20-40% of preoperative baseline 2: Minimal: no dressing changes required 2: Acceptable control per the patient; controlled with PO meds 2: Minimal: treat with PO meds 2: Steady gait, no dizziness 2: Within 20% of preoperative baseline Surgical Bleeding Pain Nausea and Vomiting Activity Vital Signs (BP and Pulse)
  12. 12. PACU Standards <ul><li>1. All patients who have received general anesthesia, regional anesthesia, or monitored anesthesia care should receive postanesthesia management. </li></ul><ul><li>2. The patient should be transported to the PACU by a member of the anesthesia care team that is knowledgeable about the patient’s condition. </li></ul><ul><li>3. Upon arrival in the PACU, the patient should be re-evaluated and a verbal report should be provided to the nurse. </li></ul><ul><li>4. The patient shall be evaluated continually in the PACU. </li></ul><ul><li>5. A physician is responsible for discharge of the patient. </li></ul>
  13. 13. Nausea and Vomiting <ul><li>Most common complication in the PACU. </li></ul><ul><li>DDX: </li></ul><ul><ul><li>Hypoxia </li></ul></ul><ul><ul><li>Hypotension </li></ul></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Anxiety </li></ul></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Chemotherapy </li></ul></ul><ul><ul><li>Gastrointestinal obstruction </li></ul></ul><ul><ul><li>Narcotics/ volatile anesthetics/ etomidate </li></ul></ul><ul><ul><li>Movement </li></ul></ul><ul><ul><li>Vagal response </li></ul></ul><ul><ul><li>Pregnancy </li></ul></ul><ul><ul><li>Increased ICP </li></ul></ul><ul><li>Do: </li></ul><ul><ul><li>IV fluids </li></ul></ul><ul><ul><li>Medications (Zofran/ Phenergan/ Promethazine) </li></ul></ul><ul><ul><li>Propofol </li></ul></ul>
  14. 14. Respiratory Complications <ul><li>Nearly two thirds of major anesthesia-related incidents may be respiratory. </li></ul><ul><ul><li>Airway obstruction </li></ul></ul><ul><ul><li>Hypoxemia </li></ul></ul><ul><ul><ul><li>Low inspired concentration of oxygen </li></ul></ul></ul><ul><ul><ul><li>Hypoventilation </li></ul></ul></ul><ul><ul><ul><li>Areas of low ventilation-to-perfusion ratios </li></ul></ul></ul><ul><ul><ul><li>Increased intrapulmonary right-to-left shunt </li></ul></ul></ul>
  15. 15. Respiratory Complications <ul><li>Do: </li></ul><ul><ul><li>Go to see the patient! </li></ul></ul><ul><ul><li>Assess the patients vital signs and respiratory rate. </li></ul></ul><ul><ul><li>Evaluate the airway. R/o obstruction or foreign body. </li></ul></ul><ul><ul><li>Mask ventilate with ambu if necessary. </li></ul></ul><ul><ul><li>Intubate and secure the airway. </li></ul></ul><ul><ul><li>Look for causes of hypoxia. </li></ul></ul><ul><ul><ul><li>Send ABG, CBC, BMP. Get CXR. </li></ul></ul></ul>
  16. 16. Failure to Regain Consciousness <ul><li>Preoperative intoxication </li></ul><ul><li>Residual anesthetics: IV or inhaled </li></ul><ul><li>Profound neuromuscular block </li></ul><ul><li>Profound hypothermia </li></ul><ul><li>Electrolyte abnormalities </li></ul><ul><li>Thromboembolic cerebrovascular accident </li></ul><ul><li>Seizure </li></ul>
  17. 17. Myocardial Ischemia <ul><li>Increased risk: </li></ul><ul><ul><li>History of CAD </li></ul></ul><ul><ul><li>CHF </li></ul></ul><ul><ul><li>Smoker </li></ul></ul><ul><ul><li>HTN </li></ul></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Severe hypoxemia </li></ul></ul><ul><ul><li>Anemia </li></ul></ul><ul><li>Same risk if the patient has GA or regional anesthesia. </li></ul><ul><li>Treatment </li></ul><ul><ul><li>Oxygen, ASA, NTG, and morphine if needed </li></ul></ul><ul><ul><li>12 lead EKG </li></ul></ul><ul><ul><li>History </li></ul></ul><ul><ul><li>Consult cardiology </li></ul></ul>
  18. 18. Fever <ul><li>Causes: </li></ul><ul><ul><li>Infections </li></ul></ul><ul><ul><li>Drug / blood reactions </li></ul></ul><ul><ul><li>Tissue damage </li></ul></ul><ul><ul><li>Neoplastic disorders </li></ul></ul><ul><ul><li>Metabolic disorders </li></ul></ul><ul><ul><ul><li>Thyroid storm </li></ul></ul></ul><ul><ul><ul><li>Adrenal crisis </li></ul></ul></ul><ul><ul><ul><li>Pheochromocytoma </li></ul></ul></ul><ul><ul><ul><li>MH </li></ul></ul></ul><ul><ul><ul><li>Neuroleptic malignant syndrome </li></ul></ul></ul><ul><ul><ul><li>Acute porphyria </li></ul></ul></ul>
  19. 19. Bibliography <ul><li>Miller: Miller’s Anesthesia, 6 th ed. (2005) </li></ul><ul><li>Baresh: Clinical Anesthesia, 4 th ed. (2001) </li></ul><ul><li>Morgan: Clinical Anesthesiology, 3 rd ed. (2002) </li></ul>