2. Group Members
• Henry William Ngoe - HSM201-0134-2018
• Steven Odhiambo Oundo - HSM201-0118/2018
• Stacy Wangui - HSM201-0229/2018
• Morefu Mercy Mwende - HSM201-0228/2018
• Minyiri Robert Acheri TM226-3405/2013
• Muturi Innocent Mukami - HSM201-0131/2018
• Bonface Nyamweya - HSM201-0038/2018
3. Post operative patient care
Objectives
1.The role of anaesthesia care unit ( PACU)
2. Procedures in PACU
-handing over of patients from OR to PACU
- Care of patients in PACU
- handing over of patients to wards
3. discharge criteria from PACU
4. Post operative complications and appropriate intervention
5. continuity of care of surgical pts in the wards
- fluids, nutrition and pain management
4. Transport from OR to PACU
• Conscious, awake, response to commands
• Haemodynamically stable
• Patent airway, adequate ventilation and o2 saturation
• Normothermia
• Gurnery should be able to position the patient in head-up or back-up
position
• Head-down -> hypovolemia
• Back-up -> pulmonary dysfunction
• Lateral position-> vomiting, upper airway bleeding
5. The role of PACU
• Allow anaesthetic agent to wear off
• Monitoring and observation
• Patency of airway
• Adequate ventilation and oxygenation
• Stable haemodynamic
• Adequate pain control
• Monitoring temperature
6. Handing over patient from OR to PACU
• Anesthetist and a qualified theatre practitioner should accompany
patient to PACU
• Hand over from anesthetist to PACU nurse
• The handing over can be verbal or a written hand-off.
7. Hand- over details:-
• Patients details i.e name,age…
• The relevant preoperative history
• Pertinent intra op events e.g. type of anaesthesia, surgical procedure, blood
loss, fluid replacement, antibiotics/relevant medication given, any
complications
• Expected post op problems
• Post anaesthesia orders e.g
• -analgesia and nausea and vomiting therapy
• -epidural or perineural catheter care
• - administration of fluids and blood products
• - post operative ventilation
• - cxr
8. Care of patients in PACU
• The responsibility of PACU staff include:-
• Airway mngt and oxygen administration
• Monitoring vital signs ( pr, bp, temp, spo2)
• Level of consciousness of pts
• Pain management
• Rx of post operative nausea and vomiting
• Rx of anaesthetic shivering
• Monitor surgical site for bleeding
• IVF administration, i/o monitoring chart
9. Hand-over of patients from PACU to ward practitioner
• The average PACU stay is 1-3 hrs, but varies.
• PACU nurse verbally hands over pts to ward practitioner. This
includes:-
• Patients details, allergy status, type of surgery and anesthesia
• Analgesia and anaesthesia given during PACU
• Any problems that occurred in PACU
• IV lines should be flushed before discharge
• Specific post op instructions should be given
12. SYSTEMIC COMPLICATIONS
RESPIRATORY SYSTEM
• Airway obstruction
• Hypoventilation
• Hypoxemia
CARDIOVASCULAR SYSTEM
• Hypertension
• Hypotension
• Arrhythmia
• Stroke
• Myocardial ischemia
CENTRAL NERVOUS SYSTEM
• Post-op delirium
• Stroke
• Seizures
13. SYSTEMIC COMPLICATIONS
GENITOURINARY SYSTEM
• Acute kidney injury
• Urinary retention
• Urinary tract infection
GASTROINTESTINAL SYSTEM
• Post operative nausea and vomiting (PONV)
• Paralytic ileus
14. POSTOPERATIVE NAUSEAAND VOMITING
• Postoperative nausea and vomiting (PONV) is common following
general anesthesia, occurring in 30% to 40% of all patients.
• It is more common in women than men and in younger patients.
15. Physiology of the vomiting centre and the chemoreceptor
trigger zone
16. Risk Factors for Postoperative Nausea and Vomiting
Patient Factors Surgical Factors Anaesthetic Factors Postoperative factors
Female patients Gynaecology Administration of opioids
intra and post-op
Pain
History of motion
sickness
ENT Use of nitrous oxide Anxiety
Previous history of PONV Strabismus surgery Use of volatile
inhalational anaesthetics
(e.g. ether)
Hypotension
Non-smokers Breast surgery Intravenous anaesthetics
(e.g. ketamine
Dehydration
Young Patients Laparotomy
Craniotomy
18. Non-pharmacological treatments of PONV
• Ginger root
• Acupuncture at the Pericardium 6 point (5cm proximal to the palmar
aspect of the wrist, between the flexor carpi radialis and palmaris
longus tendons)
• Perioperative hypnosis
19. Prevention of PONV
• Omitting nitrous oxide
• Omitting anticholinesterase drugs ( For reversal of neuromuscular
blockade) at the end of surgery
• Use of Propofol
• Avoid Use of Ether
20. RESPIRATORY COMPLICATIONS
• Majority of the respiratory problems encountered in the Post
anesthesia care unit are related to airway obstruction, hypoventilation,
or hypoxemia.
21. Airway Obstruction
• Most common cause: tongue falling back against the posterior
pharynx.
• Other causes include: laryngospasm, glottic edema, secretions,
vomitus, a retained throat pack or blood in the airway, or external
pressure on the trachea (most commonly from a neck hematoma).
• Partial airway obstruction - sonorous respiration
• Total obstruction - Absence of breath sounds, May be accompanied by
paradoxic movement of the chest
22. Management of Airway Obstruction
• Supplemental oxygen while corrective measures are undertaken
• A combined jaw-thrust and head-tilt maneuver, and insertion of an oral
or nasal airway
• For laryngospasm: The jaw-thrust maneuver, with gentle positive
airway pressure via a tight-fitting face mask; Suction secretions;
Intravenous succinylcholine and positive-pressure ventilation with
100% oxygen
• Endotracheal intubation; cricothyrodotomy if intubation is
unsuccessful
• For glottic edema: Intravenous corticosteroids or aerosolized racemic
epinephrine
23. Hypoventilation
• Defined as a PaCO2 >45 mm Hg
• Clinically apparent when the PaCO2 is >60 mm Hg or arterial blood
pH is <7.25.
• Signs include: excessive somnolence, airway obstruction, slow
respiratory rate, tachypnea with shallow breathing, or labored
breathing
• Hypoventilation in the PACU is most commonly due to the residual
depressant effects of anesthetics on respiratory drive.
24. Management of Hypoventilation
• Continuous capnography
• Continuous pulse oximetry
• Treat the underlying cause
• For opioid induced respiratory depression – Naloxone
• For hypoventilation due to pain and splinting following upper
abdominal or thoracic procedures - intravenous or intraspinal opioid
administration
25. Hypoxemia
• Signs include restlessness and tachycardia. Obtundation, bradycardia,
hypotension, and cardiac arrest are late signs
• Hypoxemia in the PACU is usually caused by hypoventilation,
increased right-to-left intrapulmonary shunting, or both.
• Causes of marked right-to-left intrapulmonary shunting include:
prolonged intraoperative hypoventilation with low tidal volumes,
unintentional endobronchial intubation, lobar collapse from bronchial
obstruction by secretions or blood, pulmonary aspiration, or
pulmonary edema.
26. Management of Hypoxemia
• Oxygen therapy
• Mild to moderate hypoxemia - 30% to 60% oxygen
• Severe or persistent hypoxemia - 100% oxygen via a nonrebreathing
mask or an endotracheal tube
• Treat the underlying cause
• Pneumothorax - Chest radiograph; Chest tube insertion
• Bronchospasm - aerosolized bronchodilator therapy
• Diuretics should be given for circulatory fluid overload
28. TREATMENT
• The patient should first be assessed for other treatable causes of
hypertension such as pain control and anxiety
• Mild to moderate elevations can be treated with intravenous beta
adrenergic blockers e.g.Labetalol,esmolol or an ACE inhibitor
e.g.enalapril or Calcium channel blocker be.Nifedipine
• Patients with marked elevations should be treated with iv infusionof
nitropusside ,nitroglycerin,nicardipine,clevipam or fenoldopam. The
end point of treatment when pressures are consistent with pateint,s
own blood pressure.
29. Hypotension
Its relatively due to hypovolemia,left ventricular dysfunction,or
excessive arterial vasodilation.
Other causes include;
• Underlying heart condition e.g. CHF
• Allergic reactions & sepsis
• cardiac tamponade
• Anaesthetic reaction e.g.spinal or epidural anaesthesia
30. TREATMENT
• Significant reduction of about 20-30% of blood pressures below
patients baseline requires correction.
• Increased in blood pressure following fluid bollus-250-500ml
crystalloid or 100-250ml of colloid generally confirms hypovolemia
• In severe hypotension a vasopressor maybe necessary to increase
arterial blood pressure until vascular deficit is corrected
• Cardiac tamponade or tension pneumothorax requires
pericardiocentesis and needle compression.
31. ARRHYTHMIAS
• Are very common complication after cardiac surgery and represent a major
source of morbidity and mortality.
• Atrial arrhythmias are the most common with ventricular arrhythmias
occurring less often
• Causes ;
Age-increasing in age has a higher chance of developing arrhythmia because
of the age-related structural or electrophysiology changes that appear to lower
the threshold for postop arrhythmias.
Underlying structural heart disease- postop arrthymia are more likely to occur
in those with structural heart disease
Underlying cormobidities-previous stroke, history of chronic obstructive
pulmonary disease
32. Residual effects of anaesthetics agent
Respiratory disturbances eg hypoxemia, hypercarbia and acidosis
TREATMENT
• Antithromotic therapy- patients with Afib are at risk of
thromboembolic events thus appropriate medications are prescribed .
Warfarin
• Antiarrhythmic agents-Sotalol,procainamide,amiodarone
• In sustained fibrillations a cardiac defibrillator maybe fixed
33. GENITURINARY SYSTEM COMPLICATIONS
Urinary retention
• General anesthetics act as smooth muscle relaxants and lead to
decreased bladder contractility while at the same time interfering with
the autonomic regulation of the detrusor. The documented substantial
increase in bladder capacity in the setting of a general anesthetic
objectively demonstrates this. Spinal and epidural anesthetics impact
voiding in an entirely different way by effectively interfering with the
afferent and efferent nerves and micturition reflex arcs as they enter
and exit the spinal cord and make their way up to the central
micturition centers.In general, the risk of POUR is most significant in
spinal anesthetics, followed by epidural anesthetics followed by
general anesthetics.
34. • Perioperative medications may also play a role in the development of
POUR. Opioids, in particular, decrease the sensation of bladder
distension by inhibiting the parasympathetics servicing the bladder while
also increasing the bladder neck tone through overstimulation of the
sympathetic nervous system leading to an increase in outlet obstruction.
• Surgical pain, via activation of the sympathetic nervous system or
colloquially termed “fight or flight” nervous system, leads to detrusor
relaxation and bladder neck contraction—essentially a constant bladder
filling stage as described by the mechanisms above.
• Finally, the destruction of anatomy vital to voiding can lead to POUR as
well. Pelvic surgeries, in particular, place the autonomic nervous system
and pelvic plexi at risk. Great efforts have been made to embrace nerve-
sparing procedures when able.
36. NEUROPSYCHIATRIC COMPLICATIONS
Post operative Delirium
• Delirium -Neuroinflammatory condition characterized by inattention
and fluctuating of consious level.
• Length -upto 30 days postoperative
• Surgeries: cardiac, vascular, orthopedics.
• Etiology: age , cognitive impairement,sleep disruption, emergency
surgeries significant intraoperative bleeding, poorly controlled pain.
• Types: hypoactive , hyperactive ,mixed
37. • Diagnosis and screening : DSM V criteria, 3D CAM, 4AT
• Anaesthesia: bispectral index
• Drugs: benzodiazepines, ketamine , dexmedotomide
• Prolonged fasting should be avoided and maintain hydration
38. TREATMENT
• Identify patient risk factors
• Mobilise early, nutrition andfluid therapy.
• Avoid benzodiazepines and anticholinergic
• Reorient patient back to family
• Treat with behavioral therapy and non pharmacological.
39.
40. HYPOTHERMIA
• Is temprature below 36 degree celcius
• Risk factors:age,abdominal surgery, long surgeries.
• Clinical features :shivering
• Treatment: small doses of meperidine 12.5 -25 mg.
• Sedate and a muscle relaxant in intubated and mechanically ventilated
patients
• Forced air warming device, warming blankets.
41. MALIGNANT HYPERTHERMIA
• Is a genetic hypermetabolic muscle disease with phenotypical signs
and symptoms with exposure of inhaled general anaesthesia.
• Clinical features: succinyl masseter muscle rigity, fever, sweating,
cyanosis, hypertension, arrythmias
• LAB : mixed metabolic respiratory acidosis with a base deficits,
hyperkalemia, hypernatremia, hypermagnesia, reduced mixed venous
oxygen saturation.
42. Drugs factors
• Ether, halothene, enflurane, isoflurane , desflurane, sevoflurane,
methoxyflurane -inhaled general anaesthesia.
• Non depolarizing muscle relaxant -succinylcholine
Treatment
• Discontinue volatile agents, succylcholine.
• Hyperventilate on 100 % oxygen
• Administer Dantrolene therapy
43. Treatment continued
• Correct metabolic acidosis with IV sodium bicarbonate
• Hyperkalemia-glucose , insulin, diuresis with furosamide
• Antiarrythmias and vasopressor if indicated
• Cooling : icepacks ,cooling ventilation, cooling blanket and
hypothermic cardiopulmonary bypass.
44. PAIN
• Pain –unpleasant sensory and emotional experience associated with
actual or potential tissue damage.
• Can be assessed subjectively or objectively.
46. OBJECTIVE
• Look for clinical features of pain;
• Unwillingness to mobilise
• Sweating
• Agitation
• tachycardia
47. Factors affecting post-op pain
• Genetics
• Age
• Previous pain experience
• Degree of operative trauma
• Psychological factors-fear and anxiety
48. Post-op causes of pain
• Incision site pain
• IV site-needle trauma
• Tubes –drains ,ETT
• Movement- ambulation, physiotherapy
• Respiratory causes- coughing, deep breathing
• Others-too tight dressing , urinary retention
49. Management of pain
• Use multidisciplinary approach
• Objectives
• Patient comfort
• Early mobilization
• Speed up recovery
• Reduce risk of complications
• Maintain muscle power
50. Poor management may lead to;
• Hypercoagulable states
• Diminished range of movement
• Psychological diseases-anxiety and depression
• Diminished range of movement
• Prolonged hospital stay and overuse of analgesics
• Litigations from relatives
56. Local anaesthesia
Bind sodium channels preventing propagation of Ap
Examples
• Lidocaine-fast onset,short duration of action(3mg/kg)
• Bupivacaine-slow onset,longer duration of action
• Ropivacaine-less cardiotoxic
57. Epidural analgesia
• Epidural morphine 3-5mg
• Epidural catheter –fentanyl 50-100mcg or sufentanyl 20-30mg with 5-
10 ml of bupivacaine
Nerve block
• Control pain isolated to a small area of the body
61. Pre-requisites
• Age,wt,vitals,hydration status, urine output
• Pre-op Dx and type of surgery
• Intra-op blood loss estimation
• Drain output, Ng tube output, wound site loss
• Associated illness-CKD, HTN, CHF, DM
64. Classification of Fluid Mx
1.Maintenance fluid
• Replace amount of fluid and electrolytes lost( remember fluid loss in
normal adult)
• Use Holiday Seggar formula i.e 4:2:1 rule or 100:50:20 rule
• Example-normal saline, dextrose etc
65. 2.Replacement fluid
• Formulated to correct fluid losses caused by;
• Gastric drainage
• Vomiting and diarrhea
• Intestinal trauma
• Oozing from trauma site
• Example-ringers lactate
66. 3.Special fluid
• Used in arising/confounding conditions E.g hypoglycemia,
hypokalemia, metabolic acidosis
• Example-sodium carbonate, dextrose, potassium chloride.
67. Nutrition Mx
• Malnutrition occurs in about 30% of surgical patients with GIT disease
• In up to 60% with prolonged hospital stay because of post-op
complications
68. Goals
Identify malnourished pt prior to surgery
Special care for comorbid disease e.g DM
Recognize when nutritional support is needed and when to
implement /stop
Meet energy requirement for normal metabolic
process(30kcal/kg/day, Amino acid-1.5g/kg/day, electrolytes and
vitamins)
Maintain core body temperature
Speed healing and tissue repair
