Prof mridul panditaro post anaesthesia care unit

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Here Prof. Mridul M. panditrao, tries to explain, the concept of Post Anaesthesia care PAC and PACU, with graphics etc.

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Prof mridul panditaro post anaesthesia care unit

  1. 1. Dr. Mridul M. Panditrao Consultant Public hospital Authority’s Rand Memorial Hospital Freeport, Grand Bahama Commonwealth of Bahamas
  2. 2. The Post- Anaesthesia Care (PAC)
  3. 3. Introduction Recovery from anesthesia can range from completely uncomplicated to life-threatening. Must be managed by skilled medical and nursing personnel. Anesthesiologist plays a key role in optimizing safe recovery from anesthesia Must be carried out in a well planned, protocol based fashion
  4. 4. PAC DefinitionIt is the specialized care given to the patientswho have undergone anaestheticmanagement, by a team of well trainedprofessionals, in a speciallydesigned, equipped and designated area ofthe hospital
  5. 5. PAC Vs. Post operative care PAC is provided to anyone who has undergone anaesthesia anaesthesia might not be for a surgical procedure patients undergoing ECT, Narco analysis patients under going Endoscopies + all the patients who have undergone surgeries
  6. 6. PACUDefinition : It is the Specially designated Specially designed Specially located Specially staffed Specially equipped Area of hospital, for a Specific purpose !
  7. 7. History of the PACU Methods of anesthesia have been available for more than 160 years, the PACU has only been common for the past 50 years. But one can trace it to “Lady of the lamp”: F. N. 1920’s and 30’s: several PACU’s opened in the US and abroad. It was not until after WW II that the number of PACU’s increased significantly. This was due to the shortage of nurses in the US. 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. 1949: having a PACU was considered a standard of care.
  8. 8. PACU Location Should be located close to the Operating Theater Immediate access to x-ray, blood bank, blood gas and clinical labs. An open ward is optimal for patient observation, with at least one isolation room. Central nursing station. Piped in oxygen, air, and vacuum for suction. 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.
  9. 9. Design of PACU Size:  Ideal 1.5 PACU bed for every Operating Room  120 square foot per patient  Minimum of 7 feet between beds Facilities:  Fowler’s cot with side rails  Piped Oxygen, Vacuum and Air  Multiple electrical outlets  Large doors  Good lighting  Isolation for Immuno-compromised patients
  10. 10. PACU Staffing One nurse to one patient for the first 15 minutes of recovery. Then one nurse for every two patients. The anesthesiologist responsible for the anesthetic remains responsible for managing the patient in the PACU. Adequate no. of ancillary staff, such as technicians, ward boys and ayahs.
  11. 11. PACU Equipment Multi-parametric monitors (Automated BP, pulse ox, ECG) and intravenous supports should be located at each bed. Area for charting, bed-side supply storage, suction, and oxygen flow meter at each bed- side. Capability for arterial and CVP monitoring. Supply of immediately available emergency equipment, Crash cart, Defibrillator.
  12. 12. Routine Post-Anaesthesia Care Criteria for shifting from OR---to---PACU  Conscious, awake, responds to simple commands  Haemo dynamic stability  Clinical evaluation and complete recovery from NM blockade  Maintenance of Oxygen Saturation  Normothermia
  13. 13. PACU Standards 1. All patients who have received general anesthesia, regional anesthesia, or monitored anesthesia care should receive postanesthesia management. 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. 3. Upon arrival in the PACU, the patient should be re- evaluated and a verbal report should be provided to the nurse. 4. The patient shall be evaluated continually in the PACU. 5. Anaesthsiogist, concerned is responsible for discharge of the patient.
  14. 14. Admission Report Preoperative history Intra-operative factors:  Procedure  Type of anesthesia  Estimated Blood Loss (EBL)  Urine output Assessment and report of current status Post-operative instructions
  15. 15. Postoperative Pain Management Intravenous opioids Diclofenac, I.V. Paracetamol and anti- inflammatory drugs Midazolam for anxiety Epidural : LAAs and their adjuvants Regional analgesic blocks PCA and PCEA
  16. 16. 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 prior to discharge from PACU Criteria for discharge developed by the Anesthesia department Criteria depends on where the patient is sent – ward, ICU, home
  17. 17. 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)
  18. 18. Discharge From the PACU Standard Aldrete Score:  Simple sum of numerical values assigned to activity, respiration, circulation, consciousness, and oxygen saturation.  A score of 9 out of 10 shows readiness for discharge. Post-anesthesia Discharge Scoring System:  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.
  19. 19. Standard Aldrete Score Activity Respiration Circulation Consciousness Oxygen Saturation2: Moves all 2:Breaths deeply 2: BP + 20 mm 2:Fully awake 2: Spo2 > 92%extremities and coughs of on room airvoluntarily/ on preanestheticcommand freely. level1: Moves 2 1: Dyspneic, 1: BP + 20-50 1: Arousable on 1:Supplementalextremities shallow or limited mm of calling O2 required to breathing preanesthetic maintain Spo2 level >90%0: Unable to 0: BP + 50 mm 0: Not responding 0: Spo2 <92% with 0: Apneic O2move of preanestheic supplementationextremities level
  20. 20. Post-anesthesia Discharge ScoringSystem (PADSS) Vital Signs Activity Nausea and Pain Surgical (BP and Vomiting Bleeding Pulse)2: Within 20% of 2: Steady gait, 2: Minimal: treat 2: Acceptable 2: Minimal: nopreoperative no dizziness with PO meds control per the dressingbaseline patient; changes controlled with required PO meds1: 20-40% of 1: Requires 1: Moderate: 1: Not 1: Moderate: uppreoperative assistance treat with IM acceptable to the to 2 dressingbaseline medications patient; not changes controlled with PO medications0: >40% of 0: Unable to 0: Continues: 0: Severe: morepreoperative ambulate repeated than 3 dressingbaseline treatment changes
  21. 21. Safe guidelines for discharging tohome 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)
  22. 22. Post Operative Complications Nausea and Vomiting Respiratory Complications Failure to Regain Consciousness Circulatory Complications Fever
  23. 23. Nausea and Vomiting Most common complication in the PACU. DDX:  Hypoxia  Hypotension  Pain  Anxiety  Infection  Chemotherapy  Gastrointestinal obstruction  Narcotics/ volatile anesthetics/ etomidate  Movement  Vagal response  Pregnancy  Increased ICP Do:  IV fluids  Medications (Ondansetron/ metoclopramide/ Promethazine)  position
  24. 24. Respiratory Complications Nearly two thirds of major anesthesia-related incidents may be respiratory Do:  Go to see the patient!  Assess the patients vital signs and respiratory rate.  Evaluate the airway. R/o obstruction or foreign body.  Mask ventilate with ambu if necessary.  Intubate and secure the airway.  Look for causes of hypoxia.  Send ABG, CBC, BMP. Get CXR.
  25. 25. Respiratory Complications  Airway obstruction  Hypoxemia  Low inspired concentration of oxygen  Hypoventilation  Areas of low ventilation-to-perfusion ratios  Increased intrapulmonary right-to-left shunt  Increased Left to Right shunt
  26. 26. Respiratory 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
  27. 27. Respiratory Complications Hypoxemia:  Low FIO2:  Diffusion hypoxemia (N2O 31 times more soluble than O2)  Hypoventilation:  Inadequate N.M. blockade recovery  Respiratory depressant effect of volatile agents, narcotics, benzodiazepines  Hypocapnia intra operatively  Upper abdominal incisions
  28. 28. Respiratory 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
  29. 29. Failure to Regain Consciousness Preoperative intoxication Residual anesthetics: IV or inhaled Profound neuromuscular block Profound hypothermia Electrolyte abnormalities Thromboembolic cerebrovascular accident Seizure
  30. 30. Circulatory Complications:  Hypotension:  Decreased preload  Decreased myocardial contractility  Increased after load
  31. 31. Circulatory 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
  32. 32. Circulatory Complications: Hypertension:  Pain  Hypercapnia  Hypothermia  Hypoxemia  Excess Intra vascular volume  Pre-existing hypertension
  33. 33. Circulatory Complications: Arrythmias:  Electrolyte imbalance ( K )  Hypoxia  Hypercarbia  Metabolic acidosis
  34. 34. Circulatory Complications: Myocardial Ischemia Increased risk:  History of CAD  CHF  Smoker  HTN  Tachycardia  Severe hypoxemia  Anemia Same risk if the patient has GA or regional anesthesia. Treatment  Oxygen, Streptokinase, NTG and morphine if needed  12 lead EKG  History  Consult cardiology
  35. 35. Fever Causes:  Infections  Drug / blood reactions  Tissue damage  Neoplastic disorders  Metabolic disorders  Thyroid storm  Adrenal crisis  Pheochromocytoma  MH  Neuroleptic malignant syndrome  Acute porphyria
  36. 36. Summary & Conclusion Anaesthesia is becoming very sophisticated! PAC is an absolutely essential care given by a team of professionals!! Anaesthesiologists and Trained nursing staff are the most important members of PACU!!! Thorough understanding of pathophysiology of this period is very essential!!!! With well organized PACU, one can prevent lot of post-operative morbidity & mortality!!!!!!

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