A Postanesthesia Care Unit (PACU) or an area which provides equivalent postanesthesia care. shall be available to receive patients after anesthesia care. PACU and sometimes referred to as post-anesthesia recovery or PAR, or simply Recovery is a vital part of hospitals, ambulatory care centers, and other medical facilities.
4. 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
4
5. 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
5
6. PURPOSES
To enable a successful and faster recovery of
the patient 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 patient cost during
post operative period.
6
7. PAC Vs. Post operative care
PAC is provided to
anyone who has undergone anaesthesia
anaesthesia might not be for a surgical
procedure
patients undergoing ECT, Narco analysis
patients under going Endoscopies
+
all the patients who have undergone
surgeries
7
8. PACU
Definition : It is the
Specially designated
Specially designed
Specially located
Specially staffed
Specially equipped
for a
Specific purpose !
8
9. History of the PACU
9
Methods of anesthesia have been available for more
than 160 years, but the PACU has only been common
for the past 70 years.
One can trace it to “Lady of the lamp”: F. N.
1920’s and 30’s: several PACU’s opened in the US and
abroad.
It was not until after WW II that the number of PACUs
increased significantly. This was due to the shortage of
nurses in the US.
In 1947 a study was released which showed that over an
11 year period, nearly half of the deaths that occurred
during the first 24 hours after surgery were preventable.
1949: having a PACU was considered a standard of
care.
10. PACU Location
10
Shouldbe locatedclose to the OperatingTheater
Immediateaccesstox-ray,bloodbank,bloodgasandclinical
labs.
Anopenwardisoptimalforpatientobservation,withatleast
oneisolationroom.
Centralnursingstation.
Requiresgoodventilation,becausetheexposuretowaste
anestheticgasesmay be hazardous.
National Institute of Occupational Safety (NIOSH) has
establishedrecommendedexposure limitsof 25 ppm for
nitrousoxideand2 ppmforvolatileanesthetics.
11. 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
11
12. PACU
PACU should be sound
proof, painted in soft colour,
isolated and these features
will help the patient to
reduce anxiety and promote
comfort.
12
16. 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.
16
17. 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.
17
19. 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
19
20. PACU Standards
1. All patients who have 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 the anesthesia care team that is
knowledgeable about the patient’s condition.
3. Upon arrival in the PACU, the patient should be re-
evaluated and a verbal report should be provided to
the nurse.
4. The patient shall be evaluated continually in the
PACU.
5. Anaesthesiogist, concerned is responsible for
discharge of the patient.
20
21. PHASES OF POST OP UNIT
Two phases-
Phase I
Phase II
21
22. Phase I
It is the immediate recovery phase
and requires intensive nursing care
to detect early signs of complication.
Receive a complete patient record
from the operating room which to
plan post operative care.
It is designated for care of surgical
patient immediately after surgery
and patient requiring close
monitoring
22
23. Phase II
Care of the surgical patient who has
been transferred from the Phase I
post op unit.
Patient requiring less observation
and less nursing care than Phase I
This phase is also known as Step
down or progressive care unit.
23
24. Admission Report
Preoperative history
Intra-operative factors:
Procedure
Type of anesthesia
Estimated Blood Loss (EBL)
Urine output
Assessment and report of current status
Post-operative instructions
24
25. Postoperative Pain Management
Intravenous opioids
Diclofenac, I.V. Paracetamol and anti-
inflammatory drugs
Midazolam for anxiety
Epidural : LAAs and their adjuvants
Regional analgesic blocks
PCA (Patient controlled analgesia) and PCEA
25
31. NURSING MANAGEMENT IN POST
OP UNIT
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 patient’s O2
saturation.
Skin colour.
31
35. Protect airway
By proper positioning of
patient’s head.
By clearing airway.
Oxygen therapy.
Pharyngeal obstruction
can occur when the
patient lies on the back
as there are chances for
tongue to fall back.
35
36. Maintaining IV 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
37. ASSESSMENT OF THE SURGICAL SITE
Hemorrhage
It is a serious
complication of surgery
that can result 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 will fall rapidly.
37
38. Blood transfusion if
necessary.
The surgical site + incision
should always be inspected.
If bleeding- pressure dressing
placed.
If the bleeding is concealed,
the patient is taken in OR for
emergency exploration of
concealed hemorrhage in
body cavity.
2/4/2015 3:47:57 PM 38
39. KEEP THE PATIENT WARM
39
Use warmer(Bair
Hugger) blankets
Use warm lights
40. Relieving pain +Anxiety
40
Administer opioid
analgesia as per
Doctor’s order.
Epidural analgesia.
NSAIDS.
Psychological support to
relieve fear+To give
support.
41. Post Operative Complications
41
Nausea and Vomiting
Respiratory Complications
Failure to Regain Consciousness
Circulatory Complications
Fever
42. Controlling Nausea + Vomiting
This is common
problem in post
operative period.
Medication can be
administered as per
doctor’s order.
Example:
Inj Metoclopramide
Inj Ondansetron
(Emeset /Zofran)
42
46. 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
46
47. 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)
47
48. Discharge From the PACU
Standard 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.
Post-anesthesia 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.
48
49. ALDRETESCORE
Post-AnesthesiaScore
Atotal discharge scoreof8-10is necessary
Post-Anesthesia Score
PRE-ANESTHESIAVITAL SIGNS/SOURCE TIME ADM 15" 30" 45" 1' 2' 3' 4' DISCHARGE
SYSTOLIC BP 20% OF PRE-ANESTHETIC LEVEL
2
CIRCULATION 20-50% 1
>50 0
FULLY AWAKE 2
CONCIOUSNES AROUSABLE ON CALLING 1
S
NOT RESPONDING 0
WARM, DRY SKIN W/ PREPROCEDURAL
COLORING 2
COLOR PALE, DUSKY, BLOTCHY, JAUNDICED, OTHER
1
CYANOTIC 0
ABLE TO DEEP BREATHE & COUGH FREELY
2
RESPIRATION DYSPNEA OR LIMITED BREATHING APKEIC
1
0
ABLE TO MOVE 4
EXTREMITIES
2
ACTIVITY ABLE TO MOVE 2
EXTREMITIES
1
ABLE TO MOVE 0 0
50. Aldrete Score
Activity Respiration Circulation Consciousness Oxygen
Saturation
2: Moves all
extremities
voluntarily/ on
command
2:Breaths deeply
and coughs
freely.
2: BP + 20 mm of
pre-anesthetic
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
pre-anesthetic
level
1: Arousable on
calling
1:Supplemental
O2 required to
maintain Spo2
>90%
0: Unable to
move
extremities
0: Apneic 0: BP + 50 mm of
preanestheic level
0: Not responding 0: Spo2 <92% with
O2
supplementation
51
51. Interpretation of Aldrete’s score
Lowest score = 0 – 2
Score for patient to be shifted to next level of
care = 9
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
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
51
52. Post-anesthesia Discharge Scoring
System (PADSS)
Vital Signs
(BP and
Pulse)
Activity Nausea and
Vomiting
Pain Surgical
Bleeding
2: Within 20% of
preoperative
baseline
2: Steady gait,
no dizziness
2: Minimal: treat
with PO meds
2: Acceptable
control per the
patient;
controlled with
PO meds
2: Minimal: no
dressing
changes
required
1: 20-40% of
preoperative
baseline
1: Requires
assistance
1: Moderate:
treat with IM
medications
1: Not
acceptable to the
patient; not
controlled with
PO medications
1: Moderate: up
to 2 dressing
changes
0: >40% of
preoperative
baseline
0: Unable to
ambulate
0: Continues:
repeated
treatment
0: Severe: more
than 3 dressing
changes
52
53. 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 ‘
53
54. Teaching, Patient Self Care
Expected out comes
Immediate post
operative changes
Written instructions like
Wound care
Activity+dietary
recommendation
Medications
Follow up
54
55. Safe guidelines for discharging to
home after ambulatory surgery
55
Patient should be able to stand & take a few
steps ( sit on bed if C/ I for standing)
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)
56. Summary & Conclusion
Anaesthesia is becoming very sophisticated!
PAC is an absolutely essential care given by a
team of professionals!!
Anaesthesiologists and Trained nursing staff
are the most important members of PACU!!!
Thorough understanding of pathophysiology of
this period is very essential!!!!
With a well organized PACU, one can prevent
lot of post-operative morbidity & mortality!!!!!!
56