Post Anesthesia Care Unit

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Post Anesthesia Care Unit

  1. 1. POST ANAESTHESIA CARE UNIT (PACU) DR.SHAILENDRA.V.L. SPECIALIST IN ANAESTHESIA . AL BUKARIYA GENERAL HOSPITAL .
  2. 2. Introduction <ul><li>Importance of PACU </li></ul><ul><li>Adequate preparedness </li></ul><ul><li>Sudden complication </li></ul>
  3. 3. History of PACU <ul><li>1947: Anaesthesia Study Commission report </li></ul><ul><li>Experience of trauma management in 2nd World War </li></ul><ul><li>Advances in Surgery in 50’s and 60’s </li></ul><ul><li>Day care surgery concept of the 90s </li></ul>
  4. 4. Design of PACU <ul><li>Location: </li></ul><ul><ul><li>Close to Operating Rooms </li></ul></ul><ul><ul><li>Easy access to Lab, X-ray, Blood bank </li></ul></ul><ul><ul><li>Close to ICU </li></ul></ul><ul><li>Size: </li></ul><ul><ul><li>Ideal 1.5 PACU bed for every OR </li></ul></ul><ul><ul><li>120 square foot per patient </li></ul></ul><ul><ul><li>Minimum of 7 feet between beds </li></ul></ul>
  5. 5. Design of PACU <ul><li>Facilities: </li></ul><ul><ul><li>Fowler’s cot with side rails </li></ul></ul><ul><ul><li>Piped Oxygen, Vacuum and Air </li></ul></ul><ul><ul><li>Multiple electrical outlets </li></ul></ul><ul><ul><li>Large doors </li></ul></ul><ul><ul><li>Good lighting </li></ul></ul><ul><ul><li>Isolation for Immuno-compromised patients </li></ul></ul>
  6. 6. Equipments in PACU <ul><li>Tray with labeled Emergency drugs </li></ul><ul><li>Airway maintenance kit: </li></ul><ul><ul><li>Laryngoscope with all size blades </li></ul></ul><ul><ul><li>All sizes Endotracheal tubes </li></ul></ul><ul><ul><li>Face masks, Airways, Ambu Bag, Venturi masks </li></ul></ul><ul><ul><li>Tracheostomy set </li></ul></ul><ul><ul><li>ICD set </li></ul></ul><ul><ul><li>Transport ventilator </li></ul></ul>
  7. 7. Equipments in PACU <ul><li>Personnel: </li></ul><ul><ul><li>Requirement varies </li></ul></ul><ul><ul><li>1 : 1 ratio good </li></ul></ul><ul><ul><li>1 : 3 ratio acceptable for busy OR’s </li></ul></ul><ul><li>Monitors: </li></ul><ul><ul><li>ECG </li></ul></ul><ul><ul><li>Pulse oximeter </li></ul></ul><ul><ul><li>Non invasive BP </li></ul></ul><ul><ul><li>EtCO 2 </li></ul></ul><ul><ul><li>Invasive pressure monitor </li></ul></ul><ul><ul><li>Temperature </li></ul></ul>
  8. 8. Routine Post-Anaesthesia Care <ul><li>Criteria for shifting from OR---to---PACU </li></ul><ul><ul><li>Conscious, awake, responds to simple commands </li></ul></ul><ul><ul><li>Haemo dynamic stability </li></ul></ul><ul><ul><li>Clinical evaluation for NM blockade recovery </li></ul></ul><ul><ul><li>Maintainance of Oxygen Saturation </li></ul></ul><ul><ul><li>Normothermia </li></ul></ul>
  9. 9. Transportation to PACU <ul><li>Fowler’s cot with side rails </li></ul><ul><li>Patient handed over to PACU nurse by the Anaesthesiologist </li></ul>
  10. 10. Care in PACU <ul><li>Monitoring : ECG, SpO 2 , Blood pressure </li></ul><ul><li>Oxygen therapy </li></ul><ul><li>Pain therapy, anti-emetics </li></ul><ul><li>Blood Pressure recording: </li></ul><ul><ul><li>Every 5 minutes for 30 minutes </li></ul></ul><ul><ul><li>Every 15 minutes for next 30 minutes </li></ul></ul>
  11. 11. Post Operative Complications <ul><li>Respiratory Complications: </li></ul><ul><ul><li>Airway obstruction </li></ul></ul><ul><ul><li>Hypoxemia </li></ul></ul><ul><ul><li>Increased Left to Right shunt </li></ul></ul>
  12. 12. Post Operative Complications <ul><li>Airway Obstruction: </li></ul><ul><ul><li>Sagging tongue: Treated with triple maneuver </li></ul></ul><ul><li>Laryngeal Spasm: </li></ul><ul><ul><li>Due to secretions </li></ul></ul><ul><ul><li>Due to irritable airways (smokers) </li></ul></ul><ul><ul><ul><li>Rx: 100% Oxygen through face mask </li></ul></ul></ul><ul><ul><ul><li>Hydrocoritsone 100 mg IV </li></ul></ul></ul><ul><ul><ul><li>If no improvement rapid intubation to secure the airway </li></ul></ul></ul>
  13. 13. Post operative Complications <ul><li>Hypoxemia: </li></ul><ul><ul><li>Low FIO 2 : </li></ul></ul><ul><ul><ul><li>Diffusion hypoxemia (N 2 O 31 times more soluble than O 2 ) </li></ul></ul></ul><ul><ul><li>Hypoventilation: </li></ul></ul><ul><ul><ul><li>Inadequate N.M. blockade recovery </li></ul></ul></ul><ul><ul><ul><li>Respiratory depressant effect of volatile agents, narcotics, benzodiazepines </li></ul></ul></ul><ul><ul><ul><li>Hypocarbia intra operatively </li></ul></ul></ul><ul><ul><ul><li>Upper abdominal incisions </li></ul></ul></ul>
  14. 14. Post operative Complications <ul><li>Increased Right to Left Shunt: </li></ul><ul><ul><li>Atelectasis: </li></ul></ul><ul><ul><li>Inadvertent endobroncial intubation </li></ul></ul><ul><ul><li>Ateclectasis of the lung </li></ul></ul><ul><ul><li>Increased Shunt ( R to L ) </li></ul></ul><ul><ul><li>Blockage of Brochus by blood or mucous plug </li></ul></ul><ul><li>Pnemothorax: </li></ul><ul><ul><li>following rib injury </li></ul></ul><ul><ul><li>following CVP placement </li></ul></ul>
  15. 15. Post operative Complications <ul><li>Circulatory Complications: </li></ul><ul><ul><li>Hypotension: </li></ul></ul><ul><ul><ul><li>Decreased preload </li></ul></ul></ul><ul><ul><ul><li>Decreased myocardial contractility </li></ul></ul></ul><ul><ul><ul><li>Increased after load </li></ul></ul></ul>
  16. 16. Post operative Complications <ul><li>Decreased preload: </li></ul><ul><ul><li>Increased blood loss </li></ul></ul><ul><ul><li>Increased III space loss </li></ul></ul><ul><ul><li>Un diagnosed urinary loss </li></ul></ul><ul><ul><li>Septicemia </li></ul></ul><ul><li>Decreased myocardial contractility: </li></ul><ul><ul><li>Depressant effect of GA drugs </li></ul></ul><ul><ul><li>Pre-existing ventricular dysfunction </li></ul></ul><ul><ul><li>Per operative Myocardial infarction </li></ul></ul><ul><li>Decreased After load: </li></ul><ul><ul><li>Volatile agents depression </li></ul></ul><ul><ul><li>Septic shock </li></ul></ul><ul><ul><li>Profound decreased SVR </li></ul></ul><ul><ul><ul><li>Septic shock </li></ul></ul></ul><ul><ul><ul><li>Volatile agents effects </li></ul></ul></ul>
  17. 17. Post operative Complications <ul><li>Hypertension: </li></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Hypercapnia </li></ul></ul><ul><ul><li>Hypothermia </li></ul></ul><ul><ul><li>Hypoxemia </li></ul></ul><ul><ul><li>Excess Intra vascular volume </li></ul></ul><ul><ul><li>Pre-existing hypertension </li></ul></ul>
  18. 18. Post operative Complications <ul><li>Arrythmias: </li></ul><ul><ul><li>Electrolyte imbalance ( K ) </li></ul></ul><ul><ul><li>Hypoxia </li></ul></ul><ul><ul><li>Hypercarbia </li></ul></ul><ul><ul><li>Metabolic acidosis </li></ul></ul>
  19. 19. Post operative Complications <ul><li>Post-operative pain & agitation: </li></ul><ul><ul><li>Ascertain adequacy of Blood-Gas exchange </li></ul></ul><ul><ul><li>Evaluate for any gastric or urinary distension </li></ul></ul><ul><ul><li>Rx: small doses of narcotics. </li></ul></ul>
  20. 20. Post operative Complications <ul><li>Nausea & Vomiting: </li></ul><ul><ul><li>Frequently seen after </li></ul></ul><ul><ul><ul><li>lapraroscopic surgeries </li></ul></ul></ul><ul><ul><ul><li>Strabismus surgeries </li></ul></ul></ul><ul><ul><li>Rx with Ondansetron 4mg IV adults / child 0.1mg/kg </li></ul></ul><ul><ul><li>Metoclopromide 0.15mg/kg IV </li></ul></ul>
  21. 21. Post operative Complications <ul><li>Hypothermia & shivering: </li></ul><ul><ul><li>Air-conditioning : excessive cooling </li></ul></ul><ul><ul><li>Cold IV fluids transfused </li></ul></ul><ul><ul><li>Cold irrigating fluids used by the surgeon </li></ul></ul><ul><ul><li>Halothane anaesthesia </li></ul></ul><ul><li>Rx by warm blankets </li></ul><ul><li>Warm IV fluids </li></ul><ul><li>Inj. Pethidine 10mg IV </li></ul>
  22. 22. Discharge criteria from PACU <ul><li>“ Neither an arbitrary time limit nor a discharge score can be used to define a medically appropriate length stay in the recovery room accurately ” </li></ul>
  23. 23. Discharge criteria from PACU <ul><li>All patients must be evaluated by anesthesiologist prior to discharge from PACU </li></ul><ul><li>Criteria for discharge developed by the Anesthesia department </li></ul><ul><li>Criteria depends on where the patient is sent – ward, ICU, home </li></ul>
  24. 24. Discharge criteria from PACU <ul><li>Easy arousability </li></ul><ul><li>Full orientation </li></ul><ul><li>Ability to maintain & protect airway </li></ul><ul><li>Stable vital signs for at least 15 – 30 minutes </li></ul><ul><li>The ability to call for help if necessary </li></ul><ul><li>No obvious surgical complication (active bleeding) </li></ul>
  25. 25. Post-anesthetic Aldrete recovery score
  26. 26. Interpretation of Modified Aldrete’s score <ul><li>Lowest score = 0 – 2 </li></ul><ul><li>Score for patient to be shifted to next level of care = 0 to 8 </li></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>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 </li></ul></ul>
  27. 27. Post-anesthesia discharge scoring system
  28. 28. Safe guidelines for discharging home after ambulatory surgery <ul><li>Patient should be able to stand & take a few steps ( sit on bed if C/ I for standing) </li></ul><ul><li>Should be able to sip fluids </li></ul><ul><li>Should be able to urinate </li></ul><ul><li>Should be able to repeat post-operative management </li></ul><ul><li>Should be able to identify the escort (cognitive function) </li></ul>
  29. 29. Thank you

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