This document outlines the course objectives and content for a Post Anesthesia Care Unit (PACU) training course. The course objectives cover topics such as postoperative patient transportation and handover, PACU equipment, monitoring and roles, postoperative pain management, complications and their treatment. The document details the sessions that will cover these topics over 4 days. It also provides the assessment methods for the course and reference materials. The overall goal of the PACU training course is to educate medical professionals on providing safe and effective postoperative care to patients in the recovery phase after anesthesia and surgery.

1. Post anesthesia care Unit
(PACU)
Amanuel Sisay (MSc)
1

2. Course objectives (1/4)
• Explain techniques of postoperative patient’s
transportation.
• Recognize methods of handover for postoperative
patients.
• Recognize recovery and other positions in the PACU.
• Describe the required equipment’s and monitoring in the
PACU.
• Explore patient follow up strategies in the PACU.
• Analyze monitoring parameters in the PACU.
• Identify common postoperative complications in PACU.
• Discussed adverse outcomes of untreated postoperative
pain
2

3. Course objectives (2/4)
• Explore different modalities of postoperative pain
management.
• Describe adverse effects of different analgesics.
• Recognize the impact of PONV
• Describe the factors that predispose to PONV
• Describes prevention, treatment the basic pharmacology of
anti-emetic drugs .
• Identify possible causes of hypoxia and hypoventilation
• Describes how to evaluate neuro-muscular blocker with the
nerve stimulator.
• Identify management of laryngospasm and other complications
of extubation
• List indications of oxygen therapy
• Describe techniques of oxygen therapy
3

4. Course objectives (3/4)
• Describes the causes and management of postoperative atelectasis,
tachycardia, bradycardia, arrhythmias, bleeding, hypotension and hypertension.
• Describe mechanisms and management of hypothermia.
• Describes the possible causes and management of postoperative confusion
and cognitive deterioration.
• Identify conditions that need higher level of postoperative care.
• Explain discharge criteria (Modified Aldrete Criteria )from PACU (in-
hospital or home)
• Identify organizational and structural requirements of the PACU
• Identify common critical incidents (Cardiorespiratory arrest) in the PACU
and early warning assessment methods
• Arrange the organization and requirements of safe PACU
• Interpret monitoring parameters and intervene accordingly.
• Evaluates neuromuscular blockade using a nerve stimulator.
4

5. Course objectives (4/4)
• Administer oxygen with different techniques (nasal
prongs, facemasks…)
• Assess postoperative pain.
• Prescribes appropriate postoperative analgesia.
• Prescribes appropriate postoperative fluid regimes
• Manage amenable bleeding and provide resuscitation.
• Prevent, assess and manage hypothermia in the PACU
5

6. Session 1: (Start from tomorrow)
• Organization, staffing and safety of PACU
• Admission and discharge criteria to PACU
• Transportation handover and positioning
• Equipment and monitoring required in the PACU
• Physiology, assessment, management of postoperative
acute pain
6

7. Session 2:
• Mechanisms, impacts, factors, prevention and
management of PONV
• Causes of hypoxia and hypoventilation, oxygen therapy
• Identification prevention and management of other
common postoperative complications (atelectasis,
tachycardia, bradycardia, arrhythmias, bleeding, hypotension,
hypertension, hypothermia, confusion and cognitive
deterioration )
7

8. Session 3:
• Assessment and management of Post anesthesia cognition
and confusion
• Assessment for discharge from PACU (in-hospital and
home)
• Reassuring and helping patients in CRC manner and
develop interdepartmental communication and collaboration
8

9. Methods of Assessment (1/1)
• Formative
• Drills, essay exams,
quizzes, and practical test
(direct observation of skills)
• Structured feedback
report
• Logbook
• Portfolio
• DOP, PCE, CBD
• And other assessment
methods
• Summative
• Progressive/ Continuous
assessment: (10%)
• DOP, PCE, CBD: (15%)
• Written exam (50%)
• Objectively Structured
Clinical Examination (OSCE):
(15%)
9

10. Reference Books
• Paul G Barash: Handbook of Clinical Anesthesia (6th edition).
Lippincott Williams & Wilkins publications, Inc., 2009.
• Paul G Barash: Clinical Anesthesia (7th edition). Lippincott Williams
&Wilkins publications, Inc., 2014.
• Ronald D. Miller: Millers Anesthesia (8th edition). Churchill
Livingstone publication, An Imprint of Elsevier, 2015.
• G. Edward Morgan: Clinical Anesthesiology (5th edition). McGraw-
Hill Companies, Inc., 2006
• Ronald D. Miller: Basics of Anesthesia (7th edition). Saunders, an
imprint of Elsevier Inc. 2011.
• Fleisher: Anesthesia and Uncommon Diseases, (5th edition).
Elsevier Saunders Inc., 2005
• James C. Duke: Duke’s Anesthesia Secretes (5th edition). Saunders, 10

11. Postanesthesia Recovery
• Patients recovering from an anesthetic has circumstances that
require individualized problem-oriented approach.
• Postanesthesia recovery must continue to adapt to meet the
needs of the changing - - perioperative landscape
- advances in technology
- changing surgical techniques
- to respond to improved evidence-based research
11

12. Levels of Postoperative/Postanesthesia
Care
• anesthesia services expand to cover a variety of patient types
• everincreasing areas outside the operating room
• selecting the correct type of recovery is essential
12

13. • many differing anesthesia areas ranging from inpatient
surgery, ambulatory surgery, to off-site procedures
• the level of postoperative care that a patient requires is
determined by:
• the degree of underlying illness, comorbidities, and the duration
• the type of anesthesia and surgery.
13

14. • Phase I recovery would be reserved for more intense recovery
and would require more one-on-one care for staff.
• Phase II recovery should be less intensive and is appropriate
for patients after less invasive procedures requiring less
attention from nursing while recovering.
• If separation of different phases of care is not possible, then
providing the appropriate level of monitoring and coverage to
the degree of postoperative impairment achieves similar
results in a single PACU area.
14

15. Postanesthetic Triage
• Triage should be based on
• clinical condition,
• length/type of procedure and anesthetic,
• the potential for complications that require intervention.
• Arbitrary criteria should not be used for determining the level
of recovery care.
• age,
• ASA classification,
• ambulatory versus
• inpatient versus off-site procedure status
• type of insurance
15

16. • intensive procedures and patients with greater acuity,
bypassing the PACU
• direct admission to intensive care units can reduce demands
on the PACU
• reduce errors with decreased number of hand offs
16

17. Safety in the Postanesthesia Care Unit
• Every PACU should have medical oversight in the form of a
medical director
• Medical director must ensure the PACU environment is as safe
as possible for both patients and staff
• Beyond usual safety policies, maintain staffing and training to
ensure that an appropriate coverage and skill mix is available
to deal with unforeseen crises.
• Incidence of adverse events in the PACU correlates with
nursing workload and staff availability.
• Ideally, all staff should have PACU certification, and staffing
ratios should never fall below acceptable standards 17

18. • The staff is obligated
• to optimize each patient’s privacy and dignity
• to minimize the psychological impact of unpleasant or frightening
events.
• Observance of procedures for handwashing, sterility, and
infection control should be strictly enforced.
• Access to the PACU should be strictly controlled.
• Increasing acceptance of reuniting patients with
family/friends, safety and privacy issues need to be
continually addressed.
18

19. • The PACU environment must also be safe for professionals.
• Air handling should guarantee that personnel are not exposed
to unacceptable levels of trace anesthetic gases (although
trace gas monitoring is not necessary)
• Staff members receive appropriate vaccinations, including
those for hepatitis B, flu, and others required by their
institution.
• Personal protective equipment (PPE) such as
• gloves and eye protection
• Worn to protect both the patient and provider
• Having masks, gowns, and appropriate particulate respiratory
equipment easily accessible is needed for particular cases. 19

20. Routine Post-Anaesthesia Care
Criteria for shifting from
OR---to---PACU
□ Haemo dynamic stability
□ Clinical evaluation and
complete recovery from
NM blockade
□ Maintenance of Oxygen
Saturation
□ Normothermia
<C9ATL

21. -
- , a . j cow.,
Transport of client from OR to RR
r avoid exposure
r avoid rough handling
r avoid hurriedmovement and rapid changes in
position.

22. Admission Report
Preoperative history
Intra-operative factors:
• Procedure
• Type of anesthesia
• Estimated Blood Loss (EBL)
. Urine output
·You seem quieter tonight. Did they
giveyousomething tohelpyourelax?"
Assessment and report of current status
Post-operative instructions

23. PACU
• Vital signs are recorded as often as
necessary but at least every 15 minutes
while the patient is in the unit.

24. PACU
Oxygenation
• pulse oximetry
Ventilation
• Resp Rate, airway patency, capnography
Circulation
• BP, HR, ECG
Level of consciousness

25. • Patient may feel the following up to 24 hours
- Sore throat
- Aching muscles
- General malaise
• Shivering - not uncommon
- Warm cotton blankets applied as necessary
- Warm air blanket may be utilized
- Medication is used for extreme shivering
2')

26. 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 PACU accurately
•All patients must be evaluated by anesthesiologist/trained staff prior to
discharge from PACU
•Criteria for discharge developed by the Anesthesia department
•Criteria depends on where the patient is sent - ward, ICU, home

27. 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)

28. Discharge From the PACU
Standard Aldrete Score:
::i Simple sum of numerical values assigned to
activity, respiration, circulation, consciousness,
and oxygen saturation.
o A score of 9 out of 1O shows readiness for
discharge.
Post-anesthesia Discharge Scoring System:
o 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.

29. ALDRETESCORE
Post-AnesthesiaScore
Atotaldischargescoreof8-10isnecessary
Post-AnesthesiaScore
PRE-ANESTHESIAVITALSIGNS/SOURCE TIME ADM1s- 3
0
-45" 1' 2' 3
' • DISCHARGE
SYSTOLIC BP 20% OF PRE-ANESTHETIC LEVEL
CIRCULATION 20-50%
>so
2
1
0
)
CONCIOUSNES
FULLYAWAKE
AROUSABLEONCALLING
2
1
s
NOTRESPONDING 0
WARM, DRY SKIN WI PREPROCEDURAL
COLORING 2
COLOR PALE, DUSKY
, BLOTCHY
, JAUNDICED, OTHER
CYANOTIC
1
0
ABLE TO DEEP BREATHE & COUGH FREELY
RESPIRATION APKEIC
2
DYSPNEA OR LIMITED BREATHING
1
0
CTJVITY
ABLETOMOVE4 EXTREMITIES 2
ABLETOMOVE2EXTREMITIES 1
ABLETOMOVEOEXTREMITIES 0
COM NiJi 3,41,.;a JIM TOTAL so

30. Activity Respiration Circulation Consciousness Oxygen
Saturation
2: Movesall
extremities
2:Brealhs deeply
and coughs
2: BP + 20 mm of
pre-anesthetic
2:Fully awake 2: Spo2> 92%
on room air
voluntarily/ on
command freely.
level
1: Moves2
extremities
1: Dyspneic,
shallow or limited
breathing
1: BP+ 20-50 mm
pre-anesthetic
level
1: Arousable on
calling
1:supplemental
02 require<! to
maintain Spo2
>90%
0: Unable lo
move
extremities
0: Apneic 0: BP + 50 mm of
preanestheic level
0: Not responding O:Spo2 <92% with
02
supplementation
Aldrete Score

31. Interpretation of Aldrete's score
Lowest score = 0 - 2
Score for patient to be shifted to next level of
care= 9
o 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
a 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
2/.J/2mS 3:48:01 PM 52

32. Vital Signs
(BP and
Pulse)
Activity Nausea and
Vomiting
Pain Surgical
Bleeding
2: Within 20% ef
preoperative
2: Steady gait,
no dizziness
2: Minimal: treat
with PO meds
2: Ac:ceptable
controlper the
2: Minimal: no
dressing
baseline patient;
controlled with
changes
required
POmeds
1: 20-40% of
preoperative
1: Requires
assistance
1: Moderate:
treat with IM
1: Not
acceptable to the
1: Moderate: up
to 2 dressing
baseline medications patient; not changes
controlled with
PO medications
0: >40% of
preoperative
baseline
0: Unable to
ambulate
0: Continues:
repeated
treatment
0: Severe: more
than 3 dressing
changes
( @ A T L A S
Post-anesthesia Discharge
Scoring System (PADSS)
S3

33. Discharge from the Post Operative Unit
A patient remains in the post op unit, until
the patient has fully recovered from -...._- _::::..:::..
anesthesia.
Following measures are used to
determine the patient ready for
discharge from post operative unit:
Stable vital signs
Orientation to Person, Place
Time or events
Adequate oxygen saturation level.
Urine out put at least 30ml/hour
Minimal pain.
Adequate respiratory function.
Aldrete score more than ' 9 ' "You'll be glod to know your daughter's
surgery went fineond she's owoke Clndtextlng."
2/.J/21l153:48:01 PM

34. Teaching, Patient Self Care
((9ATLA Expected out comes
Immediate post
operative changes
Written instructions like
Wound care
Activity+dietary
recommendation
Medications
Follow up
2/4/2015 3:48:01 PM ss