Fmc postop period

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Fmc postop period

  1. 1. POSTOPERATIVE PERIOD Romel M. Almoro, M.D., D.P.B.A. Department of Anesthesia Our Lady of Fatima University
  2. 2. 2 “The success of a major operation depends on the intensive postop care of the patient” http://student.britannica.com/comptons/article- 210788/surgery
  3. 3. 3 DEFINITION: RecoveryDEFINITION: Recovery . . .an ongoing process that begins from the end of intraoperative care until the patient returns to his/her preoperative physiological state. Marshall SI, Chung F. Discharge criteria and complications after ambulatory surgery. Anesth Analg 1999; 88: 508–17.
  4. 4. 4 Early recovery the discontinuation of anesthetic agents until recovery of protective reflexes and motor function -Awad IT and Chung F. Factors affecting recovery and discharge following ambulatory surgery, Can J Anesth 2006;53:9, 858-72. PLATINUM 24 HRS AFTER SURGERY when patients are particularly vulnerable and where decision – making is important
  5. 5. 5 Intermediate recovery when the patient achieves criteria for discharge Late recovery when the patient returns to his/her preoperative physiological state. Awad IT and Chung F. Factors affecting recovery and discharge following ambulatory surgery, Can J Anesth 2006;53:9, 858-72.
  6. 6. 6 JOURNEY OF A SURGICAL PATIENT
  7. 7. FACTORS THAT DETERMINE THE NEED FOR POST-OP CARE:  underlying illness  duration and complexity of anesthetic and surgical procedure  possibility of post-op complications
  8. 8. 8 ASA STANDARDS FOR POSTANESTHESIA CARE (Approved by the House of Delegates on October 12, 1988 and last amended on October 27, 2004) STANDARD I All patients who have received general anesthesia, regional anesthesia or monitored anesthesia care shall receive appropriate postanesthesia management.
  9. 9. 9 STANDARD II A patient transported to the PACU shall be accompanied by a member of the anesthesia care team who is knowledgeable about the patient’s condition. The patient shall be continually evaluated and treated during transport with monitoring and support appropriate to the patient’s condition.
  10. 10. 10 STANDARD III Upon arrival in the PACU, the patient shall be re- evaluated and a verbal report provided to the responsible PACU nurse by the member of the anesthesia care team who accompanies the patient.
  11. 11. 11 STANDARD IV The patient’s condition shall be evaluated continually in the PACU. STANDARD V A physician is responsible for the discharge of the patient from the PACU.
  12. 12. 12 COMPONENTS OF A PACU ADMISSION REPORT PREOP HISTORY INTRAOP FACTORS CURRENT STATUS POSTOP INSTRUCTIONS (Mecca RS. Postoperative Recovery. In: Barash PG, Collen BF and Stoelting RK. Clinical Anesthesia
  13. 13. 13 PREOPHISTORY Medication allergies or reaction Pertinent earlier surgical procedures Underlying medical illness Chronic medications Acute problems - ischemia, acid-base status, dehydration Premedications NPO status COMPONENTS OF A PACU ADMISSION REPORT PREOP HISTORY Intraop Factors Current Status Postop Instructions
  14. 14. 14 INTRAOPFACTORS Surgical procedure and type of anesthetic Relaxant/reversal status Time and amount of opioids Estimated blood loss and urine output Unexpected surgical or anesthetic events Intraop vital signs ranges Intraop laboratory findings Drugs givens (steroids, diuretics, antibiotics, vasocative meds) COMPONENTS OF A PACU ADMISSION REPORT Preop History INTRAOP FACTORS Current Status Postop Instructions
  15. 15. 15 CURRENTSTATUS Airway patency and ventilatory adequacy LOC, BP, HR and rhythm ETT position Intravascular volume status Functions of invasive monitors Size and location of IV catheters Anesthetic equipment (epidural catheter) Overall impression COMPONENTS OF A PACU ADMISSION REPORT Preop History Intraop Factors CURRENT STATUS Postop Instructions
  16. 16. 16 POSTOPINSTRUCTIONS Expected airway and ventilatory status Acceptable VS ranges Acceptable urine output and blood loss Surgical instructions (wound care) Anticipated CV problems Orders for therapeutic interventions Diagnostic tests to be secured Therapeutic goals and points prior to discharge Location of responsible physician COMPONENTS OF A PACU ADMISSION REPORT Preop History Intraop Factors Current Status POSTOP INSTRUCTIONS
  17. 17. CARE/MONITORS  oxygenation via face mask  vital signs should be taken every 15 minutes for the first hour use of pulse oximeter and single lead continuous ECG capnograph or ABG determination for high- risk patients with compromised ventilatory functions
  18. 18. DESIGN AND STAFFING LOCATION AND AREA near the operating room with good access to immediate CXR, blood bank, blood gas and other laboratory services
  19. 19. DESIGN AND STAFFING PERSONNEL: Nursing Ratio 1 nurse: 3 patients 1 nurse: 1 critical patient BEDS 2 RR beds for every 4 procedures in 24 hours
  20. 20. PULMONARY COMPLICATIONS  Airway obstruction  Hypoxemia  Aspiration  Hypoventilation
  21. 21. lead to progressive hypoxemia PaCO2 : inc. 6 mmHg for the 1st min then 3 – 4 mmHg/min Over-sedation of patient AIRWAY OBSTRUCTION PULMONARY COMPLICATIONS Airway obstruction Hypoxemia Aspiration Hypoventilation
  22. 22. MANAGEMENT  chin lift maneuver  oral/nasal airway  positive pressure ventilation with 100% oxygen  succinylcholine with assisted ventilation  orotracheal intubation AIRWAY OBSTRUCTION PULMONARY COMPLICATIONS Airway obstruction Hypoxemia Aspiration Hypoventilation
  23. 23. ETIOLOGIES: low inspired concentration of oxygen increased intra-pulmonary R-L shunt (most common) pulmonary edema pulmonary embolism post-hyperventilation diffusion hypoxia PULMONARY COMPLICATIONS Airway obstruction Hypoxemia Aspiration Hypoventilation HYPOXEMIA
  24. 24. ETIOLOGIES:  reduced cardiac output  shivering  inc. O2 consumption 500x  type of anesthetic MONITOR: pulse oximeter (measures oxygen saturation) TREATMENT: adequate oxygenation HYPOXEMIA PULMONARY COMPLICATIONS Airway obstruction Hypoxemia Aspiration Hypoventilation
  25. 25. ASPIRATION more common among patients with full stomach PULMONARY COMPLICATIONS Airway obstruction Hypoxemia Aspiration Hypoventilation
  26. 26. HYPOVENTILATION reduced alveolar ventilation result in an increase in the arterial CO2 due to: poor respiratory drive poor muscle function high production of CO2 presence of acute or chronic lung disease PULMONARY COMPLICATIONS Airway obstruction Hypoxemia Aspiration Hypoventilation
  27. 27. CARDIOVASCULAR COMPLICATIONS  Hypotension  Hypertension  Arrhythmia
  28. 28. HYPOTENSION ETIOLOGIES:  decreased ventricular pre-load  reduced myocardial contractility  reduction in systemic vascular resistance TREATMENT:  elevation of the legs  crystalloids, colloids and blood  combined inotropic & vasopressor support CARDIOVASCULAR COMPLICATIONS Hypotension Hypertension Arrhythmia
  29. 29. HYPERTENSION ETIOLOGIES:  pain  hypercapnea  excess IVF  pre-existing HPN CARDIOVASCULAR COMPLICATIONS Hypotension Hypertension Arrhythmia
  30. 30. ARRHYTHMIA ETIOLOGIES:  electrolyte imbalance – hypokalemia  hypoxia  hypercapnea  metabolic alkalosis and acidosis  pre-existing heart disease  common arrhythmias: ST, PVC, VT, SVT (most dangerous) & sinus bradycardia CARDIOVASCULAR COMPLICATIONS Hypotension Hypertension Arrhythmia
  31. 31. RISK FACTORS:  massive transfusion  elderly patients  pre-existing renal disease  major trauma patients  presence of sepsis  surgery on heart and great vessels  biliary surgery (with obstructive jaundice) PRESENTATION: oliguria RENAL COMPLICATIONS
  32. 32. CAUSES: coagulopathy loss of vascular integrity TESTS: clotting time prothrombin time (PT) partial thromboplastim time (PTT) fibrinogen platelet count bleeding time BLEEDING COMPLICATIONS
  33. 33. GOAL: achieve and maintain plasma level within the patient’s therapeutic window since analgesic requirement is rarely constant PAIN MANAGEMENT
  34. 34. DRUG CLASSIFICATION paracetamol NSAIDs opioids local anesthetics PAIN MANAGEMENT ROUTES OF ADMINISTRATION: oral rectal sublingual epidermal parenteral: im and iv neuraxial: epidural and spinal
  35. 35. TRADITIONAL PAIN MANAGEMENT  fixed doses  fixed intervals  fixed rate infusion PATIENT-CONTROLLED ANALGESIA (PCA) PUMP MODES  basal rate mode  PCA mode  combined basal rate and PCA mode PAIN MANAGEMENT
  36. 36. PATIENT EDUCATION explain use of PCA pump establish a trusting relationship with the patient PCA
  37. 37. Drug concentration: amount of drug in the solution Loading dose: initial dose prior to basal rate and PCA doses Lockout Interval: interval after each dose during which demands do not result in another dose being administered prevents accidental overdose Basal rate: dose of continuous infusion/hr PCA Setting
  38. 38. PCA Dose: smaller doses of the drug also called demand dose large enough to be effective while minimizing side effects One-hour Limit total amount of drug that can be administered in one hour basal rate + PCA doses in 1 hour PCA Setting
  39. 39. VISUAL ANALOG SCALE SCORE PAIN ASSESSMENT CATEGORICAL CLASSIFICATION OF PAIN 0: no pain 1 - 3: mild pain 4 - 6: moderate 7-10: severe pain 0 No pain 10 Worst pain
  40. 40. SEDATION ASSESSMENT measures the patient's responsiveness to his or her name, quality of speech, degree of facial relaxation, and ability to focus the eyes. OBSERVER’S ASSESSMENT OF ALERTNESS & SEDATION (OAAS)
  41. 41. SEDATION ASSESSMENT OBSERVER’S ASSESSMENT OF ALERTNESS & SEDATION (OAAS) Does not respond to commands or shaking5 Responds to command only after several attempts and mild prodding 4 Eyes closed. Responds to commands3 Slow response and slurred speech2 Awake1 DescriptionScore
  42. 42. 42 Known as the Post Anesthesia Recovery (PAR) Score Used in the PACU to clinically assess the physical status of patients recovering from the anesthetic experience and to follow their awakening process. Served as a basis to discharge patients from the PACU to either the hospital ward or their homes after ambulatory surgery. Adopted as the suggested criteria for discharge from the PACU by the Joint Commission of Accreditation of Health Care Organizations ALDRETE SCORE
  43. 43. 43 CRITERIA SCORE ACTIVITY Able to move four extremities voluntarily or on command 2 Able to move two extremities voluntarily or on command 1 Unable to move any extremities voluntarily or on command 0 RESPIRATION Able to breath deeply and cough freely 2 Dyspneic or with limited breathing 1 Apneic 0 CIRCULATION BP or HR + or – 20% of pre-anesthetic level 2 BP or HR + or – 21% to 49% of pre- anesthetic level 1 BP or HR + or – 50% of pre-anesthetic level 0 CONSCIOUSNESS Fully awake 2 Arousable on calling 1 Not responding 0 OXYGEN SATURATION Able to maintain O2 saturation > 92% on room air 2 Needs O2 inhalation to maintain O2 saturation > 90% 1 O2 saturation < 90% even with O2 supplement 0
  44. 44. 44 CRITERIA SCORE PAIN Pain free 2 Mild pain handled by oral meds 1 Pain requiring parenteral meds 0 DRESSING Dry 2 Wet but stationary 1 Wet but growing 0 URNE OUTPUT Has avoided freely / Adequate output with catheter 2 Unable to void but comfortable / Adequate output but requiring IV fluid maintenance 1 Unable to void and uncomfortable / Oliguric 0 AMBULATION Able to stand up and walk straight 2 Vertigo when erect 1 Dizziness when supine 0 FASTING- FEEDING Able to drink fluids 2 Nauseated 1 Nausea and vomiting 0 patients may be discharged from the care of the anesthesiologist in the PACU on attaining a Aldrete Score/PARS of 10
  45. 45. GENERAL CONDITION Oriented to time, place and surgical procedure Responds to verbal input and follows simple instructions Acceptable color without cyanosis, splotchiness or pallor DISCHARGE EVALUATION GUIDELINES General Condition Heart Rate & Rhythm Ventilation & Oxygenation Systemic BP Airway Maintenance Pain Control Renal Function Metabolic or Laboratory Ambulatory Patients
  46. 46. GENERAL CONDITION Adequate muscular strength & mobility for minimal self-care Absence or control of specific acute surgical complications (bleeding, edema, neurologic weakness, diminished pulses) Suitable control of nausea and emesis DISCHARGE EVALUATION GUIDELINES General Condition Heart Rate & Rhythm Ventilation & Oxygenation Systemic BP Airway Maintenance Pain Control Renal Function Metabolic or Laboratory Ambulatory Patients
  47. 47. HEART RATE & RHYTHM relatively constant for at least 30 minutes resolution of any new arrhythmias acceptable intravascular volume status any suspicion of MI rectified DISCHARGE EVALUATION GUIDELINES General Condition Heart Rate & Rhythm Ventilation & Oxygenation Systemic BP Airway Maintenance Pain Control Renal Function Metabolic or Laboratory Ambulatory Patients
  48. 48. VENTILATION & OXYGENATION ventilatory rate > 10 bpm and < 30 bpm forced vital capacity approximately 2x the tidal volume adequate ability to cough and clear secretions qualitatively acceptable work of breathing DISCHARGE EVALUATION GUIDELINES General Condition Heart Rate & Rhythm Ventilation & Oxygenation Systemic BP Airway Maintenance Pain Control Renal Function Metabolic or Laboratory Ambulatory Patients
  49. 49. SYSTEMIC BP within +/- 20% of resting pre- operative value AIRWAY MAINTENANCE protective reflexes (e.g. swallowing, gag) intact absence of stridor, retraction or partial obstruction no further need for artificial airway support DISCHARGE EVALUATION GUIDELINES General Condition Heart Rate & Rhythm Ventilation & Oxygenation Systemic BP Airway Maintenance Pain Control Renal Function Metabolic or Laboratory Ambulatory Patients
  50. 50. PAIN CONTROL ability to localize and identify intensity of surgical pain adequate analgesia at least 15 min since last opioid safe, appropriate orders for post-discharge analgesics DISCHARGE EVALUATION GUIDELINES General Condition Heart Rate & Rhythm Ventilation & Oxygenation Systemic BP Airway Maintenance Pain Control Renal Function Metabolic or Laboratory Ambulatory Patients
  51. 51. RENAL FUNCTION urine output > 30 ml/hr (catheterized patients) appropriate color and appearance of urine; evaluation of hematuria DISCHARGE EVALUATION GUIDELINES General Condition Heart Rate & Rhythm Ventilation & Oxygenation Systemic BP Airway Maintenance Pain Control Renal Function Metabolic or Laboratory Ambulatory Patients
  52. 52. METABOLIC OR LABORATORY acceptable hematocrit level in view of hydration, BP & potential for future losses suitable control of blood glucose appropriate electrolyte hemostasis evaluation of CXR, ECG, etc DISCHARGE EVALUATION GUIDELINES General Condition Heart Rate & Rhythm Ventilation & Oxygenation Systemic BP Airway Maintenance Pain Control Renal Function Metabolic or Laboratory Ambulatory Patients
  53. 53. AMBULATORY PATIENTS ability to ambulate without dizziness, hypotension or support suitable control of nausea & vomiting after ambulation DISCHARGE EVALUATION GUIDELINES General Condition Heart Rate & Rhythm Ventilation & Oxygenation Systemic BP Airway Maintenance Pain Control Renal Function Metabolic or Laboratory Ambulatory Patients
  54. 54. 54 Whenever doubts exist regarding the ability of patients to recover safely in unmonitored setting ADMIT PATIENT TO PACU
  55. 55. Thank you!!!

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