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
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
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
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.
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
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
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
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
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
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
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
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
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
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. 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. 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. 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
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
25. ASPIRATION
more common among patients with full stomach
PULMONARY
COMPLICATIONS
Airway obstruction
Hypoxemia
Aspiration
Hypoventilation
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
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. CAUSES:
coagulopathy
loss of vascular integrity
TESTS:
clotting time
prothrombin time (PT)
partial thromboplastim time (PTT)
fibrinogen
platelet count
bleeding time
BLEEDING
COMPLICATIONS
33. GOAL:
achieve and maintain plasma level
within the patient’s therapeutic
window since analgesic
requirement is rarely constant
PAIN MANAGEMENT
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. 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. 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. 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. 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
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
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
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. 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. 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. 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. 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. 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. 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. 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. 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. 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
Whenever doubts exist regarding
the ability of patients to recover
safely in unmonitored setting
ADMIT PATIENT TO PACU
