Post-Operative Managment • The post operative period begins from the time • The patients leaves the operating room and ends with the follow up visit by the surgeon. • The post operative care is provided by -- PACU -- SICU

1. Post-Operative
Management
Mr. Harshad Khade
MSc. Medical Technology (OTA)
Symbiosis International university, Pune.

2. Introduction
• The post operative period begins from the time
• The patients leaves the operating room and ends with the
follow up visit by the surgeon.
• The post operative care is provided by
-- PACU
-- SICU

3. Purposes of PACU

4. Purposes
• To enable a successful and faster recovery of the patients
post operatively.
• To reduce post operative mortality rate.
• To reduce the length of hospital stay of the patient.
• To provide quality care service.
• To reduce hospital and patients cost during post operative
period.

5. Post Operative Care Unit
Post Anesthetic Care Unit

6. Post Operative Care Unit
Post Anesthetic Care Unit
• Patients still under anesthesia or recovering from anesthesia
are placed in the unit for observation by highly skilled
nurses, Anesthetist and Anesthesia technologist.
• PACU should be
sound proof,
painted in soft colures
will help the patient to reduce anxiety and promote comfort.

7. PACU
Definition : it is the
• Specially designated
• Specially designed
• Specially located
• Specially staffed
• Specially equipped
For a specific purpose.

8. PACU Location

9. PACU Location
• Should be located close to the operating theater.
• Immediate access to X-Ray, blood bank, blood gas and
clinical lab.
• An open ward is optimal for patients observation, either at
least one isolation room.
• Central nursing station.
• Requires good ventilation, because the exposure to waste
anesthetic gases may be hazardous.

10. Design Of PACU

11. Design Of PACU
Size :-
• Ideal 1.5 ( 3:2 ) PACU beds for
every operating room
• 80 - 120 square foot per
patients.
• Minimum of 7 feet distance
between beds.
Facilities :-
• Fowler’s cot with side rails.
• Piped oxygen, vacuum and air.
• Multiple electrical outlets
• Large doors.
• Good lighting
• Isolation for immune
compromised patients.

12. PACU Staffing

13. PACU Staffing
• One nurse to one patient for the first 15 minutes of recovery.
• Then one nurse for every two patients.
• The anesthesiologist responsible for the anesthetic remains
responsible for managing the patient in the PACU.
• Adequate no. of ancillary staff, such as technicians, ward
boys and female attenders.

14. PACU Equipment

15. PACU Equipment
• Multi-parametric monitors ( automated NIBP, SPO2, 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.

16. Transport Of Patient
From OR To PACU

17. Transport Of Patient
From OR To PACU
• Avoid exposure
• Avoid rough handling
• Avoid hurried movement and rapid changes in position.
Criteria for shifting patient from OR to PACU
1. Hemodynamic stability.
2. Clinical evaluation and complete recovery from NM blockade.
3. Maintenance of oxygen saturation
4. Normothermia

18. PACU Standards

19. 1. All patients who hav received general anesthesia, regional
anesthesia, or monitored anesthesia care should receive post-
anesthesia management.
2. The patient should be transported to the PACU by a member of
anesthesia care team that is knowledgeable about the patients
condition. (Anesthesia Technologist)
3. Upon arrival in the PACU, the patient should be re-evaluated
and verbal report should be provided to the nurse.
4. The patient shall be evaluated continually in the PACU.
5. Anesthesiologist concerned is responsible for discharge of the
patient.

20. Phases Of Post Operative Unit

21. Phases Of Post Operative Unit
PHASE I
• It is the immediate recovery phase
and requires intensive nursing care to
detect early signs of complications.
• Receive a complete patient record
from the operating room which to
plan post operative care.
• It is designed for care of surgical
patient immediately after surgery
and patient requiring close
monitoring.
PHASE II
• Care of the surgical patient who has
been transferred from the phase I
post operative unit.
• Patient requiring less observation
and less nursing care then phase I.
• This phase is also known as step
down or progressive care unit.

22. Admission Report
• Preoperative history
• Intra-operative factors:
1. Procedure
2. Type of anesthesia
3. Estimated Blood loss
4. Urine output
• Assessment and report of current status
• Post operative instructions

23. Post-operative Pain
Management

24. Post-operative Pain
Management
• Intravenous opioids
• Diclofenac, I.V. Paracetamol and Anti Inflammatory drugs.
• Midazolam for anxiety.
• Epidural : Local Anesthetic Agent’s and their adjuvant.
• Regional analgesic blokes.
• PCA ( Patient controlled analgesia)

25. PACU Length Of Stay

26. PACU Length Of Stay
• Will vary, is dependent upon several factors.
• Type of surgery,
• patients response to surgery and anesthesia,
• medical history.
• Average length of stay is 2 to 3 hours.
• Longer stays may be necessary to meet discharge criteria.

27. • 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

28. Management In PACU

29. Management In PACU
• To provide care until the patient has recovered from the
effect of anesthesia
• Assessing the patient
• Monitor vitals-
• Pulse volume and regularity,
• depth and nature of respiration,
• Assessment of patients o2 saturation.
• Skin color.

30. Keep Monitoring Vitals

31. Check The Level Of Consciousness
Ability To Respond To Commands

32. Maintain Intake And Output

34. Protect Airway
• By proper positioning of patients head.
• By clearing airway.
• Oxygen therapy
Pharyngeal obstruction
• Can occur when the patient lies on the back as there are
chances for tongue to all back.

35. Maintaining I.V. Stability
• Hypovolemic shock can be avoided by timely administration
of IV fluids, blood and blood products and medication.
• Replacement of fluids colloids and crystalloids.
• Monitor intake and output balance.

36. Assessment Of The Surgical Site
Hemorrhage
• It is a serious complication of surgery that can results in
death.
• It can occur in immediate post operatively or up to several
days after surgery.
• If left untreated cardiac output decreases and blood pressure
and Hb level be fall rapidly.

37. Keep The Patient Warm
• Use warmer ( Bair Hugger ) blankets
• Use warm lights.

38. Post Operative Complication
• Nausea and vomiting
• Respiratory complications
• Failure to regain consciousness
• Circulatory complications
• Fever

39. Discharge Criteria From PACU

40. Discharge Criteria From PACU
• Neither an arbitrary time limit nor a discharge score can be use
to define a medically appropriate length stay in the PACU
accurately.
• All patients must be evaluated by anesthesiologist / anesthesia
technologist prior to discharge from PACU.
• Criteria for discharge developed by the anesthesia
department.
• Criteria depends on where the patient is sent–Ward, ICU, Home.

41. Discharge Criteria From PACU
• 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 )

42. Discharge From PACU

43. Discharge From PACU
• Standard Aldrete score:
• Simple sum of numerical values
assigned to activity, respiration,
circulation, consciousness and
oxygen saturation.
• A score 9 out of 10 shows
readiness for discharge.
Post-Anesthetic discharge score
system:
• Modification of the Aldrete score
which also includes an assessment
of pain, nausea, vomiting and
surgical bleeding in addition to vital
signs and activity
• also a score of 9 or 10 shows
readiness for discharge.

44. Aldrete Score

45. Points Activity Respiration Circulation Consciousness Oxygen
Saturation
2 Moves All
Extremities
(Voluntarily / On
Command)
Breaths Deeply And
Coughs Freely
BP + 20 mm Of Pre
Anesthetic Level
Fully Awake Spo2 >92% On
Room Air
1 Moves 2
Extremities'
Dyspneic Shallow
Limited Breathing
BP + 20-50 mm Of
Pre Anesthetic
Level
Arousable On
Calling
Supplemental O2
Required To
Maintained
Spo2>90%
0 Unable To Move
Extremities
Apneic BP + 50 mm Of Pre
Anesthetic Level
Not Responding Spo2 < 92% With
O2
Supplementation

46. Interpretation Of Aldretes Score
• Lowest score = 0-2
• Score for patient to be shifted to next level of care = 9
Sinece some patients on arrival to PACU will meet the score of 8, it is
very illogical to fix a number for shifting the patient.
Ideally it should be decision of the anesthesiologist regarding the
shifting from the PACU to next level of care taking in to account the
anesthetic plan & the drugs given intra-operatively as well as in PACU.

47. Post-anesthetic Discharge Score
System (PADS)
Points Vital sign
(BO & Pulse)
Activity Nausea &
vomiting
Pain Surgical
Bleeding
2 Within 20% of
preoperative
baseline
Steady gait no
dizziness
Minimal Acceptable
control per the
patient
Minimal
1 20-40% of
preoperative
baseline
Requires
assistance
Moderate Not acceptable to
the patient
Moderate
0 >40% of
preoperative
baseline
Unable to
ambulate
continues Severe

48. Discharge From
Post Operative Unit

49. • A patient remains in the post operative unit, until the patients
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 .
• Adequate oxygen saturation level
• Urine output at least 30 ml/hour
• Minimal pain
• Adequate respiratory function.
• Aldrete score more than “9”

51. Teaching Patient Self Care
• Expected outcome
• Immediate post operative changes
• Writen instruction like wound care,
• Activity + dietary recommendation
• medications
• follow up

53. Safe Guidelines For Discharging To
Home After Ambulatory Surgery
• Patient should be able to stand & take a few steps
• Should be able to sip fluids
• Should be able to urinate
• Should be able to repeat post operative management
• Should be able to identify the escort (cognitive function)

55. Summary
• Anesthesia is becoming very sophisticated !
• PAC is an absolutely essential care given by a team of
professionals !
• Anesthesiologist and Anesthesia Technologist are the most
important members of PACU !
• Through understanding of pathophysiology of this period is very
essential !
• With well organized PACU, one can prevent lot of post operative
morbidity & mortality !

56. “
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Thank You
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