post anaesthesia care management

1. PRESENTER: JASKEERATAN
Care Of Patient In PACU Including
Post Operative Pain : Evaluation
And Management

2. 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.

3. PAC
 DEFINITION
It is the specialized care given to the
patients who have undergone
anaesthetic management, by a team of
well trained professionals, in a specially
designed, equipped and designated
area of the hospital

4. PACU
Definition : It is the
 Specially designated
 Specially designed
 Specially located Area of
 Specially staffed Hospital
 Specially equipped for a
Specific purpose !

5. 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.
 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 oxide and 2 ppm for volatile
anesthetics.

6. Standards of post anesthetic care –ASA guidelines
All patients who have received general , regional
or monitored anaesthesia should receive post
anaesthetic care.
A patient transported to the PACU should be
accompanied by a member of the anaesthesia
team.
In the pacu the patient should be reevaluated and
verbal report provided to the nurse.

7.  The patient should be continually evaluated in the PACU.
A physician is responsible for the discharge of the patient
from PACU.

8. 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

9. PACU should be
sound proof,
painted in soft
colour, isolated and
these features will
help the patient to
reduce anxiety and
promote comfort.

11. 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.
 Immediately available -Emergency equipment, Crash
cart, Defibrillator

12.  number of physiologic disturbances that effect
multiple organ systems.
 Most common are postoperative nausea and
vomiting (PONV), hypoxia, hypothermia and
shivering, and cardiovascular instability.

13. Transport to the PACU
 Upper airway patency and the effectiveness of
the patient's respiratory efforts must be
monitored.
 CONFIRMATION OF Adequate ventilation (watching for
the appropriate rise and fall of the chest wall with
inspiration, listening for breath sounds, or simply feeling
for exhaled breath with the palm of one's hand over the
patient's nose and mouth.)
 WITH RARE EXCEPTION PATIENT MAY
RECEIVE SUPPLEMENTAL OXYGEN.

14. Criteria for shifting from OR to PACU
-conscious awake responds to simple
commands
- hemodynamic stability
-clinical evaluation for NM blockade
recovery
- maintenance of O 2 saturation
- normothermia

15. Post op fluid therapy
 Assesment of fluid balance in the postoperative period
Patient’s history
- preoperative history
- preoperative volume status
Surgery/ intervention
Anaesthesia
Patient’s current clinical condition

16. Empirical maintenance and replacement fluid
therapy
 MAINTENANCE FLUID THERAPY: 4-2-1 rule
 Replacement fluid therapy
 Haemorrhage : 1ml of blood loss/ 3ml crystalloid/
/ 1 ml of colloid
 Third space loss: balanced crystalloid solutions
 Profuse sweating: D5W ½ NS with 5 meq KCl /l
 Gastric and colonic losses: D5W ½ NS WITH 30
meqKCl /l
 Bile pancreas and small bowel losses: RL

17.  Emergence from general anaesthesia and
surgery may be accompanied by a number of
physiologic disturbances that affect multiple
organ systems. Most common are nausea,
vomiting(9.8%), upper airway support
(6.8%), hypotension(2.7%),hypoxia,
hypothermia and shivering, and
cardiovascular instability.

18. Nausea and vomiting
 Frequently seen after laparoscopic surgeries,
strabismus surgeries
 treated with ondansetron 4mg iv adults/child 0.1
mg/kg
 Metoclopromide 0.15mg/kg iv

19. Hypothermia and shivering
CAUSES
Air conditioning excessive cooling
 Cold iv fluids transfused
 Cold irrigating fluids used(urology,ortho)
Treatment
 warm blankets
 warm iv fluids
 Inj. Pethidine 10mg iv

20. Post anesthetic shivering can also be treated
with a variety of drugs, including
 Clonidine (75 µg IV),
 Tramadol,
 Physostigmine (0.04 mg/kg IV),
 Dexmedetomidine, and
 Magnesium Sulfate (30 mg/kg IV).

21. RESPIRATORY COMPLICATIONS
 Airway obstruction:- sagging tongue,
 Laryngeal spasm:- due to secretions,
 Hypoxemia,
 Hypoventilation: inadequate nm blockade
recovery.

22. OXYGEN SUPPLEMENTATION

23. MANOUVERES TO IMPROVE
OXYGENATION
 Enhance alveolar hypoventilation
reversal agents
opioids/ BZD antagonists
 Appropriate pain management
Periodic lung hyperinflation( improves the venous
admixture)
- incentive spirometery, CPAP, PEEP.
Patient positioning: semi recumbent position
increases FR
reduces pulmonary shunt

24. CIRCULATORY COMPLICATIONS
 Hypotention:- decreased preload: increased blood
loss, undiagnosed urinary loss,
 decreased myocardial contractility: depressent
effect of GA drugs, myocardial infarction, pre
existing ventricular dysfunction
 Decreased after load:- volatile agents depression,
septic shock
 Hypertension:- pain , hypothermia, excess intra
vascular volume, pre existing intravascular volume

25. POST OPERATIVE PAIN AND AGITATION
Acute effects of postoperative pain
Respiratory : Effects
1. Increased skeletal muscle tension - hypoxia
2. Decreased total lung compliance - hypercapnia
- atelectasis
- pneumonitis
Cardiovascular:
increased myocardial work - dysrhthmias
- angina
- CHF

26. ASSESMENT OF PAIN IN ADULTS

27. ANALGESIC LADDER- WFSA
RECOMMENDATIONS

28. OPIOID SYSTEMIC ANALGESICS
• Morphine : oral: 10-30 mg (qid)
:injection: 2- 15 mg sc/IM/IV
• Fentanyl : injection 50- 100 μg/dose
transdermal: 25 μg/hr q 72 hrs
• Tramadol : oral: 50- 100 mg qid
injection: 0.25 mg/kg iv

29. NONOPIOID SYSTEMIC ANALGESICS
Dosage: oral parenteral
PCM 10-15 mg/kg
DICLOFENAC 50- 100 mg bd 75 mg IM
KETOROLAC 10- 20 mg tds 15-30 mg IM/iv

30. PATIENT CONTROL ANALGESIA
 Background continous infusion with intermittent
boluses maintains serum drug levels in analgesic range

31. Cont..
DRUG SIZE OF BOLUS LOCKOUT
INTERVAL
CONTINUOUS
INFUSION
MORPHINE
(adult)
0.5-2mg 5-10 min. 0.1-1mg/kg
PEDIATRIC 0.01 – 0.03
μg/kg
5-10 min. 0.01-0.03
mg/kg/hr
FENTANYL
(adult)
10- 20 μg/kg 4-10min. 0.02-0.1 mg/hr
pediatric 0.5 -1 μg/kg 5-10min. o.5- 1μg/kg/hr

32. Discharge Criteria
 Alert, oriented
 A minimum mandatory stay not required
 Stable vitals
 Scoring systems may assist
 The requirement to urinate before discharge and drink and
retain clear fluids should not be a part of routine discharge
criteria
 Written instructions

33. Discharge From the PACU
 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.

34. Postanesthesia 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.

35. Aldrete Score
Activity Respiration Circulation Consciousnes
s
Oxygen
Saturation
2: Moves
all
extremities
2:Breaths
deeply and
coughs
freely
2: BP + 20
mm of
preanesthet
ic level
2:Fully
awake
2: Spo2 >
92% on
room air
1: Moves 2
extremities
1:Dyspneic,
shallow or
limited
breathing
1: BP + 20-
50 mm of
preanesthet
ic level
1:Arousable
on calling
1:Suppleme
ntal O2
required to
maintain
Spo2 >90%
0: Unable to
move
extremities
0: Apneic 0: BP + 50
mm of
preanesthei
0: Not
responding
0:
Spo2<92%
withsupple

36. Vital Signs Activity Nausea
Vomiting
Pain Surgical
Bleeding
2: Within
20% of
preoperativ
e baseline
2: Steady
gait, no
dizziness
2: Minimal:
treat with
PO meds
2:
Acceptable
control per
the patient;
2: Minimal:
no dressing
changes
required
1;20-40% of
preoperativ
e baseline
1: Requires
assistance
1:
Moderate:
treat with
IM
medications
1:Notaccept
able to the
patient; not
controlled
with PO
medications
1:
Moderate:
up to 2
dressing
changes
0: >40% of
preoperativ
e baseline
0: Unable
to ambulate
0:
Continues:
repeated
0: Severe:
more than 3
dressing

37. Thank you