The document discusses the history and importance of post-anesthesia care units (PACUs) and outlines their design, equipment, staffing needs, and standard procedures for patient care and monitoring. Key aspects of PACU care include criteria for patient transfer from the operating room to PACU, routine post-anesthesia monitoring and treatment, potential post-operative complications, discharge criteria, and scoring systems used to evaluate patient recovery status.

1. POST ANAESTHESIA CARE UNIT (PACU) DR.SHAILENDRA.V.L. SPECIALIST IN ANAESTHESIA . AL BUKARIYA GENERAL HOSPITAL .

2. Introduction Importance of PACU Adequate preparedness Sudden complication

3. History of PACU 1947: Anaesthesia Study Commission report Experience of trauma management in 2nd World War Advances in Surgery in 50’s and 60’s Day care surgery concept of the 90s

4. Design of PACU Location: Close to Operating Rooms Easy access to Lab, X-ray, Blood bank Close to ICU Size: Ideal 1.5 PACU bed for every OR 120 square foot per patient Minimum of 7 feet between beds

5. Design of PACU Facilities: Fowler’s cot with side rails Piped Oxygen, Vacuum and Air Multiple electrical outlets Large doors Good lighting Isolation for Immuno-compromised patients

6. Equipments in PACU Tray with labeled Emergency drugs Airway maintenance kit: Laryngoscope with all size blades All sizes Endotracheal tubes Face masks, Airways, Ambu Bag, Venturi masks Tracheostomy set ICD set Transport ventilator

7. Equipments in PACU Personnel: Requirement varies 1 : 1 ratio good 1 : 3 ratio acceptable for busy OR’s Monitors: ECG Pulse oximeter Non invasive BP EtCO 2 Invasive pressure monitor Temperature

8. Routine Post-Anaesthesia Care Criteria for shifting from OR---to---PACU Conscious, awake, responds to simple commands Haemo dynamic stability Clinical evaluation for NM blockade recovery Maintainance of Oxygen Saturation Normothermia

9. Transportation to PACU Fowler’s cot with side rails Patient handed over to PACU nurse by the Anaesthesiologist

10. Care in PACU Monitoring : ECG, SpO 2 , Blood pressure Oxygen therapy Pain therapy, anti-emetics Blood Pressure recording: Every 5 minutes for 30 minutes Every 15 minutes for next 30 minutes

11. Post Operative Complications Respiratory Complications: Airway obstruction Hypoxemia Increased Left to Right shunt

12. Post Operative 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

13. Post operative Complications Hypoxemia: Low FIO 2 : Diffusion hypoxemia (N 2 O 31 times more soluble than O 2 ) Hypoventilation: Inadequate N.M. blockade recovery Respiratory depressant effect of volatile agents, narcotics, benzodiazepines Hypocarbia intra operatively Upper abdominal incisions

14. Post operative 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

15. Post operative Complications Circulatory Complications: Hypotension: Decreased preload Decreased myocardial contractility Increased after load

16. Post operative 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

17. Post operative Complications Hypertension: Pain Hypercapnia Hypothermia Hypoxemia Excess Intra vascular volume Pre-existing hypertension

18. Post operative Complications Arrythmias: Electrolyte imbalance ( K ) Hypoxia Hypercarbia Metabolic acidosis

19. Post operative Complications Post-operative pain & agitation: Ascertain adequacy of Blood-Gas exchange Evaluate for any gastric or urinary distension Rx: small doses of narcotics.

20. Post operative Complications Nausea & Vomiting: Frequently seen after lapraroscopic surgeries Strabismus surgeries Rx with Ondansetron 4mg IV adults / child 0.1mg/kg Metoclopromide 0.15mg/kg IV

21. Post operative Complications Hypothermia & shivering: Air-conditioning : excessive cooling Cold IV fluids transfused Cold irrigating fluids used by the surgeon Halothane anaesthesia Rx by warm blankets Warm IV fluids Inj. Pethidine 10mg IV

22. 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 recovery room accurately ”

23. Discharge criteria from PACU 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

24. 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)

25. Post-anesthetic Aldrete recovery score

26. Interpretation of Modified Aldrete’s score Lowest score = 0 – 2 Score for patient to be shifted to next level of care = 0 to 8 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 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

27. Post-anesthesia discharge scoring system

28. Safe guidelines for discharging home 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)

29. Thank you