Postanesthetic Postanesthetic care care

Recovery roomRecovery room

Recovery rooms have been inexistence Recovery rooms have been inexistence 35-40 years35-40 years

As surgical prcedures increasing As surgical prcedures increasing complex & sicker patients recovery room complex & sicker patients recovery room care were extend beyond first few hours care were extend beyond first few hours after surgery after surgery

Some critically ill patients were kept in Some critically ill patients were kept in the RR overnight.the RR overnight.

The success of the RR was a major The success of the RR was a major factor in the evolution of modern surgical factor in the evolution of modern surgical intensive care unit. intensive care unit.

Now they refer to as post anesthetic care Now they refer to as post anesthetic care units (PACU)units (PACU)

As the conclusion of most operations, As the conclusion of most operations, anesthetics agent were discontinued, anesthetics agent were discontinued, monitors were disconnected, and the pt. monitors were disconnected, and the pt. were taken to the PACU.were taken to the PACU.

Pts .are routinely observed in the PACU Pts .are routinely observed in the PACU following regional& general anesthesia.following regional& general anesthesia.

Most guidelines require pt. to admit to Most guidelines require pt. to admit to PACU except by specific order of the PACU except by specific order of the attending anesthetist. attending anesthetist.

After brief verbal report to the PACU After brief verbal report to the PACU nurse, th pt. is left in the PACU until the nurse, th pt. is left in the PACU until the major effect of anesthesia is worn off.major effect of anesthesia is worn off.

This period is high incidence of This period is high incidence of potentially life threatening respiratory potentially life threatening respiratory &circulatory complications. &circulatory complications.

Objective of the PACUObjective of the PACU

Care &monitor pts. during anesthetic Care &monitor pts. during anesthetic wear off in the first few hours after wear off in the first few hours after surgery.surgery.

Monitor especialy respiratory & Monitor especialy respiratory & circulatory complications and vital organ.circulatory complications and vital organ.

Early detect surgical complication eg. Early detect surgical complication eg. bleeding, drainage.bleeding, drainage.

Post op painPost op pain

DesignDesign

The PACU should be locate near the OR.The PACU should be locate near the OR. A central location that the pt. can be rush A central location that the pt. can be rush

back to surgery or need staff can quickly back to surgery or need staff can quickly attend to the pt.attend to the pt.

The transfer critically ill pt. to the elevator The transfer critically ill pt. to the elevator or long corridors can jeopardise this care.or long corridors can jeopardise this care.

A ratio of 1.5 bed PACU/OR A ratio of 1.5 bed PACU/OR

EquipmentsEquipments

Full monitorings Full monitorings spo2,EKG,NIBP,sphygmomanomitors,spo2,EKG,NIBP,sphygmomanomitors,

Capnograph, transducing pressure to direct Capnograph, transducing pressure to direct arterrial ,CVP ,PCWP ,temperature arterrial ,CVP ,PCWP ,temperature

Own supplies basic &emergency equipments.Own supplies basic &emergency equipments. Catheter for vascular canulations.Catheter for vascular canulations. Oxygen equipments, respiratory therapy Oxygen equipments, respiratory therapy

equipments, ventilatorsequipments, ventilators

staffingstaffing

The PACU staff only by nurses specific The PACU staff only by nurses specific trained in the care of patients emergence trained in the care of patients emergence from anesthesia.from anesthesia.

Expertise in airways management Expertise in airways management &ACLS ,commonly problems relate to &ACLS ,commonly problems relate to wound care, draniage catheter, bleeding.wound care, draniage catheter, bleeding.

Average PACU stay is1-2hours.Average PACU stay is1-2hours.

Care of the patient,Care of the patient,emergence from general emergence from general anesthesiaanesthesia

Recovery from GA&RA is great of physiologic Recovery from GA&RA is great of physiologic stress –airways obstructionstress –airways obstruction

-shivering -shivering -agitation-agitation -delilium-delilium -pain-pain -nausea/vomiting-nausea/vomiting -autonomic lability -autonomic lability loss of loss of

compensation reflexcompensation reflex -hypothermia-hypothermia

During tarnsport to the recovery room is During tarnsport to the recovery room is frequently airways obstruct, shivering, frequently airways obstruct, shivering, agitation, delirium,pain, nausia, vomiting, agitation, delirium,pain, nausia, vomiting, hypothermia, autonomic lability.hypothermia, autonomic lability.

RA-RA-decrease in BP, symphatolytic decrease in BP, symphatolytic effects of regional block, loss of reflex effects of regional block, loss of reflex vasoconstriction.vasoconstriction.

Speed of emergence in inhalation base Speed of emergence in inhalation base anesthetic depend on alveolar ventilation, anesthetic depend on alveolar ventilation, but inverse proportion to blood gas but inverse proportion to blood gas solubility.solubility.

A duration of anesthesia,total tissue A duration of anesthesia,total tissue uptake, agent solubility, concentration use, uptake, agent solubility, concentration use, nitrus oxide use.nitrus oxide use.

The most frequent cause of delay The most frequent cause of delay emergence from inhalation anesthesia is emergence from inhalation anesthesia is hypoventilation.hypoventilation.

Emergence from intravenous anesthesia is Emergence from intravenous anesthesia is depend on redistribution rather than depend on redistribution rather than elimination half life.elimination half life.

Total drug dose& accumulation Total drug dose& accumulation effect ,advance age, hepatic ,renal effect ,advance age, hepatic ,renal disease can prolong emergence.disease can prolong emergence.

Type &dosage of pre medication, pre op Type &dosage of pre medication, pre op sleep deprivation ,drug ingest ( alcohol, sleep deprivation ,drug ingest ( alcohol, sedative) sedative)

Delay emergenceDelay emergence Pts.fail to regain conscious in 60-90 Pts.fail to regain conscious in 60-90

minutes after GA.minutes after GA. The most frequent cause is residual The most frequent cause is residual

anesthetic ,sedative ,analgesic drug effect.anesthetic ,sedative ,analgesic drug effect. Antidote Antidote naloxone , flumacinil cannaloxone , flumacinil can

exclude opioid&bensodizepine effects.exclude opioid&bensodizepine effects. Physostigmine can exclude nuromuscular Physostigmine can exclude nuromuscular

blockade.blockade.

Less common cause of delay Less common cause of delay

emergenceemergence Hypothermia esp. core temp<33 c.Hypothermia esp. core temp<33 c. Mark metabolic disturbanceMark metabolic disturbance Preoperative strokePreoperative stroke Hypoxia/hypercarbiaHypoxia/hypercarbia Hyper ca, hyper mg,hypo Na,hypo-Hyper ca, hyper mg,hypo Na,hypo-

hyperglycemiahyperglycemia

Transport from the Transport from the operating roomoperating room Usually complicate by lack of adequate Usually complicate by lack of adequate

monitors, drugs ,resuscitive equipments.monitors, drugs ,resuscitive equipments. Pt. should not leave unless stable patent Pt. should not leave unless stable patent

airway, adequate ventilation,& airway, adequate ventilation,& hemodynamic stable.hemodynamic stable.

Transport with oxygen supplemmentTransport with oxygen supplemment The positions also help either head –up, The positions also help either head –up,

head –down, lateral position.head –down, lateral position.

Routine recovery from GARoutine recovery from GA

Vital sign&o2 should be checked immediately on Vital sign&o2 should be checked immediately on arrival.arrival.

NIBP,PR,RR routinely every 5min.for 15 min.or NIBP,PR,RR routinely every 5min.for 15 min.or until stable ,and every 15 min. therafter,may be until stable ,and every 15 min. therafter,may be temperature.temperature.

After check vital signAfter check vital signcheck preop check preop history( include mental status, comunication history( include mental status, comunication problem )intra op event, expected p/o problem )intra op event, expected p/o problemsproblems ,post anesthetic order ,post anesthetic order

All pt. recover from GA should receive 30-All pt. recover from GA should receive 30-40% 0240% 02 to prevent hypoxia.to prevent hypoxia.

Continue 02 therapy at the time to Continue 02 therapy at the time to discharge base on sp02 reading on room discharge base on sp02 reading on room air. air.

Routine recovery from RRoutine recovery from RAA

Pt. who heavily sedate or hemodynamic Pt. who heavily sedate or hemodynamic unstable shouldunstable should receive 02 supplement.receive 02 supplement.

Check sensory& motor level to document Check sensory& motor level to document dissipation of blockade.dissipation of blockade.

Precaution self injury from un coordinate Precaution self injury from un coordinate extremity.extremity.

Bladder catheterization is need for longer Bladder catheterization is need for longer than 4 hours. than 4 hours.

Pain controlePain controle AgitationAgitation Nausea&vomitingNausea&vomiting shiveringshivering

Discharge criteriaDischarge criteria

Esay arousableEsay arousable Full orientationFull orientation Stability to maintain&protect airwayStability to maintain&protect airway Stable vital signs for at least 1 hoursStable vital signs for at least 1 hours The ability to call for help if necessaryThe ability to call for help if necessary No obvious surgical complications (such No obvious surgical complications (such

as active bleeding)as active bleeding)

Post anesthetic recovery Post anesthetic recovery score(PAR score)/Aldrete scorescore(PAR score)/Aldrete score Colour-pink/pale or dusky/cyanoticColour-pink/pale or dusky/cyanotic Respiration-can breath deeply&cough Respiration-can breath deeply&cough

-shallow but adequate-shallow but adequate

-apnea/obstruction-apnea/obstruction Circulation-BP within 20%of normalCirculation-BP within 20%of normal

-20-50% normal-20-50% normal

->50% normal->50% normal

Consiousness-awake /alert/orientedConsiousness-awake /alert/oriented

-arousable but readily drift back -arousable but readily drift back to sleepto sleep

- no response- no response Activity –move all extremityActivity –move all extremity

-move 2 extremity-move 2 extremity

- no movement- no movement

*failure of spial / epidural block to resolve after *failure of spial / epidural block to resolve after 6 hours possibility spinal cord /epidural 6 hours possibility spinal cord /epidural hemaotoma hemaotoma

Should be discharge when total score10Should be discharge when total score10

Thank you for your attention.Thank you for your attention.