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
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
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
PACUDefinition : It is the Specially designated Specially designed Specially located Specially staffed Specially equipped Area of hospital, for a Specific purpose !
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.
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.
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
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.
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.
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
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.
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
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
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
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)
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.
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
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
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)
Post Operative Complications Nausea and Vomiting Respiratory Complications Failure to Regain Consciousness Circulatory Complications Fever
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
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.
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
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
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
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
Failure to Regain Consciousness Preoperative intoxication Residual anesthetics: IV or inhaled Profound neuromuscular block Profound hypothermia Electrolyte abnormalities Thromboembolic cerebrovascular accident Seizure
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
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!!!!!!