The document outlines postoperative assessment and care, focusing on emergency medical problems, respiratory and hemodynamic issues, and pain management strategies. It details the admission process to the PACU, monitoring parameters, common postoperative complications, and treatments for conditions such as hypotension, hypoventilation, and postoperative nausea and vomiting (PONV). The importance of effective pain management through various methods, including pharmacologic and non-pharmacologic approaches, is also highlighted.

1. Postoperative Assessment and care
Gemechis Akuma
Lecturer at WU IHS, Dept. of Anesthesia (BSc, MSC in ACA)
Nekemte, Oromia

2. Objectives..
Objectives..
• At the end of the session the students will be able to:
1. Explain a common approach to emergency medical problems encountered in the
postoperative period.
2. Identify post-operative respiratory and hemodynamic problems and explain how to
manage these problems.
3. Explain the predisposing factors, differential diagnosis and management of PONV.
4. Identify the causes and treatments of post-operative agitation and delirium.
5. Identify the causes of delayed emergence and know how to deal with this problem.
6. Explain about different approaches of post-Operative pain management

16. Postoperative stage
• At the end of the operation, the patient is either extubated
in the OT (and an OPA inserted if needed) or transferred
to the recovery room with an LMA still in situ.?
• All patients receive supplemental oxygen during transfer.
• Many patients who do not have a general
anesthesia/sedation bypass the recovery room and go
straight from the OT to the surgical daycare unit

17. Admission to PACU
Steps:
Steps:
Coordinate prior to arrival,
• Assess airway,
• Administer oxygen,
• Apply monitors,
• Obtain vital signs,
• Receive report from anesthesia personnel.

19. Once in the recovery room,
• Handover occurs between the anesthetist and a recovery nurse.
Important information passed on includes:
• Patients name and age;
• Operation details;
• Blood loss;
• Anaesthetic technique with emphasis on:
• analgesia given;
• regional/nerve blocks;
• antiemetics given;
• antibiotics;
• the use of local anaesthetic infiltration;
• thromboprophylaxis.

20. Patient Care in the PACU
• Admission
• Apply oxygen and monitor
• Receive report
• Monitor & Observe & Manage
 To Achieve
• Cardiovascular stability
• Respiratory stability
• Pain control
• Discharge from PACU

21. Monitoring in the PACU
• Baseline vital signs.
• Respiration
• RR/min, Rythm
• Pulse oximetry
• Circulation
• PR/min & Blood pressure
• ECG
• Level of consciousness
• Pain scores

22. Initial Assessment
1. Color
2. Respiration
3. Circulation
4. Consciousness
5. Activity

23. Aldrete Score
Score Activity Respiration Circulation Consciousness Oxygen
Saturation
2
Moves all
extremities
Breaths
deeply and
coughs
freely.
BP + 20 mm
of
preanesth.
level
Fully awake Spo2 > 92%
on room air
1
Moves 2
extremities
Dyspneic, or
shallow
breathing
BP + 20-50
mm of
preanesth.
level
Arousable on
calling
Spo2 >90%
With suppl. O2
0
Unable to
move
Apneic
BP + 50
mm of
preanesth.
level
Not responding Spo2 <92%
With suppl. O2

24. Common PACU Problems
• Airway obstruction
• Hypoxemia
• Hypoventilation
• Hypotension
• Hypertension
• Cardiac dysrhythmias
• Hyper/Hypothermia
• Bleeding
• Agitation
• Delayed recovery
• “PONV”
• Pain
• Oliguria

25. Airway Obstruction
• Most common: tongue fall back
 posterior pharynx
• May be foreign body
• Inadequate relaxant reversal
• Residual anesthesia

26. Management of Airway Obstruction
• Patient’s stimulation,
• Suction,
• Oral Airway,
• Nasal Airway,
• Others:
• Tracheal intubation
• Cricothyroidotomy
• Tracheotomy

28. Hypoventilation
• Residual anesthesia
• Narcotics
• Inhalation agent
• Muscle Relaxant
• Post oper - Analgesia
• Intravenous
• Epidural

29. Treatment of Hypoventilation
• Close observation,
• Assess the problem,
• Treatment of the cause:
• Reverse (or Antidote):
• Muscle relaxant  Neostigmine
• Opioids  Naloxone
• Midazolam  Anexate

30. Hypertension
• Common causes: e.g.
• Pain
• Full Bladder
• Hypertensive patients
• Fluid overload
• Excessive use of vasopressors

31. Treatment of Hypertension
• Effective pain control
• Sedation
• Anti-hypertensives:
• Beta blockers
• Alpha blockers
• Hydralazine (Apresoline)
• Calcium channel blockers

32. Hypotension
• Decreased venous return
• Hypovolemia,
•  fluid intake
•  losses
• Bleeding
• Sympathectomy,
• 3rd space loss,
• Left ventricular dysfunction

33. Treatment of Hypotension
• Initially treat with fluid bolus,
• + Vasopressors,
• + Correction of the cause

36. Dysrhythmias
• Secondary to
• Hypoxemia
• Hypercarbia
• Hypothermia
• Acidosis
• Catecholamines
• Electrolyte abnormalities.

37. Treatment of Dysrhythmia
• Identify and treat the cause,
• Assure oxygenation,
• Pharmacological

38. Urine Output
• Oliguria
• Hypovolemia,
• Surgical trauma,
• Impaired renal function,
• Mechanical blocking of catheter.
• Treatment:
• Assess catheter patency
• Fluid bolus
• Diuretics e.g. Lasix

39. Post op Bleeding
Causes:
•Usually Surgical Problem,
•Coagulopathy,
•Drug induced

42. Treatment of Post op Bleeding
Treatment:
• Start i.v. lines  push fluids
• Blood sample,
- CBC,
- Cross matching,
- Coagulopathy
• Notify the surgeon,
• Correction of the cause

43. Hypothermia
• Most of patients will arrive cold
• Treatment:
• Get baseline temperature
• Actively rewarm
• Administer oxygen if shivering
• Take care for:
• Pediatric,
• Geriatric.

45. Altered Mental Status
• Reaction to drugs?
• Drugs e.g. sedatives, anticholinergics
• Intoxication / Drug abusers
• Pain
• Full bladder
• Hypoventilation
• Low COP
• CVA

47. Treatment of Altered Mental Status
• Reassurances,
• Always protect the patient,
• Evaluate the cause,
• Treatment of symptoms,
• Sedatives / Opioids if necessary.

49. Delayed Recovery
• Systematic evaluation
• Pre-op status
• Intraoperative events
• Ventilation
• Response to Stimulation
• Cardiovascular status

50. Delayed Recovery
• The most common cause:
• Residual anesthesia  Consider reversal
• Hypothermia,
• Metabolic e.g. diabetic coma,
• Underlying psychiatric problem
• CVA

51. Postoperative Nausea & Vomiting
“PONV”
• Commonest complication in postop
• Risk factors
• Type & duration of surgery,
• Type of anesthesia,
• Drugs
• Hormone levels,
• Medical problems,
• Autonomic involvement.

52. • Identified four risk factors: female gender, prior history of motion
sickness or postoperative nausea, nonsmoking, and the use of
postoperative opioids.
• The Apfel simplified risk score predicts PONV with 0,1, 2, 3, or 4 risk
factors as 10%, 20%, 40%, 60%, and 80%, respectively.
• Prophylactic antiemetic therapy when two or more risk factors are
present while using volatile anesthetics.
• Also able to tailor the anesthetic or possibly avoid the most likely causes
of PONV: volatile anesthetics, nitrous oxide, and postoperative opioids
altogether

54. Prevention of PONV
• NPO status
• Dexamothasone,
• Droperidol,
• Metoclopramide,
• H2 blockers,
• Ondansetron,
• Acupuncture

55. Causes:
Incisional Skin and subcutaneous tissue
Laparoscopy Insuflation of Co2
Others:
Deep cutting, coagulation, trauma
Positional nerve compression, traction & bed sore.
IV site needle trauma, extravasation, venous irritation
Tubes drains, nasogastric tube, ETT
Surgical complication of surgery
Others cast, dressing too tight, urinary retention
Postoperative Pain

56. Subjective Objective
Uni-Dimensional
Uni-Dimensional Multidimentional  Behavioral.
 Physiological.
 Neuro-endocrinal.
 Algometry.
 VRS, VAS & NRS.
 Facial expression.
 McGill P Q,
 Pain Inventory.
 ACUTE PAIN
ACUTE PAIN  Chronic Pain
Chronic Pain Both
Both
PAIN MEASUREMENTS

57. Numeric Rating Scale (NRS)
Visual Analogue Scale (VAS)
0 10
Pain Scores

58. Wong-Baker “Faces Scale”
Verbal scale
No
Pain
Mild Moderate
Severe
Pain

59. Pharmaco - Therapy
1. Local infiltration
2. Wound perfusion
3. Intra-abdominal inj. of LA/Analg.
4. Intercostal & Interpleural
5. Paravertebral
6. USG-RA: e.g. TAP
7. Neuraxial:
Epidural:
Thoracic
Lumbar
Spinal
Single shot
CSA
CSE
1. Non Opioid Analgesics
 NSAADs
 Analgesic /Antipyretic
 Analgesic/Anti-inflam/Antipyretic
 NSAIDs
 Non-selective COX inhibitors
 Selective COX-2 inhibitors
2. Opioids
 Weak Opioids.
 Strong Opioids.
 Mixed agonist-antagonists
3. Adjuvants
 -2 Agonists
 LA
 SP inhibitors
 NMDA inhibitors
 Anticonvulsant / Antidepressants
 Calcitonin
 Relaxants
 Cannabinoids
 Others
Regional Techniques
ACUTE POSTOPERATIVE MANAGEMENT TOOLS

60. WHO III Strong opioids
Mild pain (0-3)
Moderate pain (4-6)
Severe pain (7-10)
± Adjuvant
± Adjuvant
± Adjuvant
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WHO IV Interventional
By the mouth
By the clock
By the ladder
Current evidence?
WHO Ladder
Updated
WHO class II Weak opioids
WHO class I NSAIDs

61. 1. Non Opioid Analgesics
 NSAADs
 Analgesic / Anti-inflam / Antipyretic / Anticoagulant
 ASA
 Analgesic /Antipyretic
 Paracetamol
 NSAIDs
 Non-selective COX inhibitors:
 Diclofenac & Ketoprofen
 Selective COX-2 inhibitors
 Celecoxib & Rofecoxib
WHO class I NSAIDs
WHO class II Weak opioids
WHO III Strong opioids
Mild pain (0-3)
Moderate pain (4-6)
± Adjuvant
± Adjuvant
± Adjuvant
Severe pain (7-10)

62. Scientific Evidence – NON OPIOID ANALGESICS
1. Paracetamol:
1. is an effective analgesic for acute pain; the incidence of adverse effects
comparable to placebo (Level I [Cochrane Review]).
2. Paracetamol / NSAIDs given in addition to PCA Opioids   Opioid
consumption (Level I).
2. NSAIDs:
1. are effective in the treatment of acute postoperative (Level I ).
2. With careful patient selection and monitoring, the incidence of renal
impairment is low (Level I [Cochrane Review]).
3. NSAIDs + Paracetamol improve analgesia compared with paracetamol
alone (Level I).
Acute Pain Management - Scientific Evidence - AAGBI Guidelines 2010

63. WHO Ladder II - Weak Opioids:
1. Tramadol:
• Tramadol : Morphine:
• Parenteral = 1 : 10 & Oral = 1 : 5
• Dose: 200 – 400 mg/d
2. Codeine:
• Metabolized to morphine.
• Codeine : Morphine = 1 : 10
3. Dextro-propoxyphene:
• Methadone Derivative
• Prolongation of Q-T interval.
WHO class I NSAIDs
WHO class II Weak opioids
WHO III Strong opioids
Mild pain (0-3)
Moderate pain (4-6)
± Adjuvant
± Adjuvant
± Adjuvant
Severe pain (7-10)

64. Scientific Evidence – WEAK
OPIOIDS
1. Tramadol:
 has a lower risk of respiratory depression & impairs GIT motor
function < other opioids
(Level II).
 is an effective treatment for neuropathic pain
(Level I [Cochrane Review]).
2. Dextropropoxyphene:
 has low analgesic efficacy
(Level I [Cochrane Review]).
Acute Pain Management - Scientific Evidence - AAGBI Guidelines 2010

65. WHO class I NSAIDs
WHO class II Weak opioids
WHO III Strong opioids
Mild pain (0-3)
Moderate pain (4-6)
± Adjuvant
± Adjuvant
± Adjuvant
WHO Ladder III - Strong Opioids
1. Morphine:
1. Sedation
2. PONV
3. Respiratory Depression
2. Fentanyl
1. Rapid action, Short duration.
2. Fentanyl : Mophine = (1:10)
3. Pethidene:
1. Active metabolite:  t½ .
2. Prolongs Q-T interval.
3. Pethidine : Mophine = (1:10)
4. Hydromorphone:
1. Powerful, rapidly acting.
2. Release is in distal gut.
3. Hydromorphone : Morphine = 1 : 5
Severe pain (7-10)

66. WHO III Strong opioids
Mild pain (0-3)
Moderate pain (4-6)
Severe pain (7-10)
± Adjuvant
± Adjuvant
± Adjuvant
WHO IV Interventional
WHO class II Weak opioids
WHO class I NSAIDs
WHO Ladder IV – Regional Anesthetic Techniques
1. Local infiltration
2. Wound perfusion
3. Intra-abdominal LA
4. Intercostal
5. Interpleural
6. Paravertebral
7. USG - RA: e.g. TAP
8. Neuraxial:
 Epidural:
 Thoracic
 Lumbar
 Spinal
 Single shot
 CSA
 CSE

67. Neuraxial (Spinal / Epidural)
(LA / Opioids / others)
• Advantages:
• Provide prolonged & effective analgesia
• Side effects
• Respiratory depression.
• N/V.
• Pruritis.
• Urinary retention.

68. +
+ Multidisciplinary:
Multidisciplinary:
• Adjuvant therapy.
Adjuvant therapy.
• Psychotherapy.
Psychotherapy.
• Physioltherapy.
Physioltherapy.
• Causal diag. & ttt.
Causal diag. & ttt.
WHO class I
WHO class I NSAIDs
NSAIDs
WHO class II
WHO class II Weak opioids
Weak opioids
WHO III
WHO III Strong opioids
Strong opioids
LA infiltration
LA infiltration
Non-pharmacological
Non-pharmacological
Paravertebral / PNB
Paravertebral / PNB
Neuraxial LA
Neuraxial LA
Opioids
Opioids
WHO Algorithm for Management of Pain
WHO Algorithm for Management of Pain
Plexus block
Plexus block

69. Diagnosis
Procedure Specific
Pain manag. Pain Assessment
Preventive /
Preemptive
ttt of Pain and Co morbidities
1ry Treatment Supportive Treatment
Pharmacotherapy
Interventional
Psychological ttt.
Physical / Rehab.
Management Algorithm for Postoperative Pain

70. PACU Discharge Criteria
• Fully Awake, easy arrosablity
• Patent airway,
• Good respiratory function,
• Stable vital signs, at least 15-30 min
• Patency of tubes, catheters, IV’s
• Pain free,
• Reassurance of surgical site.

79. Reference
Reference.
 Clinical anaesthesia (Paul G. Barash 8th ed)
 Morgan & Mikhail’s Clinical Anesthesiology, 6th
ed
 Anaesthesia. (Ronald. D. Miller 8th ed)
 Essential Anesthesia 3rd
ed

80. T
THANK YOU!
HANK YOU!
?
?
WHO was first anesthetist?
When it was started? mid 1840?
God was first: “And the Lord God caused a deep sleep
to fall upon Adam, and he slept.” (Genesis 2:21).
A date is not mentioned?.