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1. ROLES OF THE POSTANESTHESIA CARE UNIT NURSE Nicanor I. Alfaro Jr. R.N. Head Nurse Postanesthesia Care Unit UP-PGH

2. PACU 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.

3. History of the PACU Methods of anesthesia have been available for more than 160 years, the PACU has only been common for the past 50 years. 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 PACU’s 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.

4. PACU Location Should be located close to the operating suite. Immediate access to x-ray, blood bank, blood gas and clinical labs. Should have 1.5 PACU beds per operating room used. An open ward is optimal for patient observation, with at least one isolation room. Central nursing station. Piped in oxygen, air, and vacuum for suction. Requires good ventilation, because the exposure to waste anesthetic gases may be hazardous

6. PACU Standards 1. All patients who have received general anesthesia, regional anesthesia, or monitored anesthesia care should receive postanesthesia 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. A physician is responsible for discharge of the patient.

7. The PACU nursebasic training requirements Airway management Basic life support Advanced cardiac life support (Morgan et al., 2006) Caring for acute surgical wounds Caring for a variety of drainage catheters

8. Nurse-to-patient ratios 1:1 initial 15 minutes, as the patient emerge from anesthesia, overflow from an ICU, unstable and requiring transfer to ICU 2:1 critically ill, unstable, complicated problems, newly admitted, on mechanical ventilator with an artificial airway

9. 1:2 one patient CSU (conscious, stable, and uncomplicated) and the other unconscious, but stable and uncomplicated 1:3 to 1:6 all CSU and being considered for discharge Nurse-to-patient ratios

10. Equipments needed The unit needs a full complement of airway equipment , including oxygen masks and cannulas, oral and nasal airways and tubes, tracheostomy tubes, airway scopes and ventilation bags, chest tube trays, ventilators aerosol treatment cardiac equipments such as defibrillator, pacing devices, ECG equipment, vascular cutdown trays infusion pumps, advanced life-support crash cart and a complete stock of cardiopulmonary rescue drugs.

11. Routine monitoring After general anesthesia, most patients take 15-30 minutes to become fully awake, to be breathing normally and to be physiologically stable Until a patient is awake and stable, vital signs and blood oxygenation saturation are recorded every 5 minutes. Subsequently, blood pressure, pulse rate, and respiratory rate are measured every 15 minutes Temperature is measured and recorded at least once early in the PACU stay.

12. Depending on the patient, other physiologic parameters that might be monitored regularly are: Pain Nausea Bleeding Drainage/catheters Fluid intake and output Central venous pressure Intracranial pressure

13. Oxygen supplementation All patients recovering from general anesthesia should receive 30-40% oxygen during their emergence Certain patients have a greater than normal risk of developing hypoxemia and may need supplemental oxygen during their entire stay in the PACU. These include Older adults Patients with pre-existing lung problems Thoracic or upper abdominal surgery

14. Recovery from Anesthesia The PACU team’s aim is for patients to emerge gradually from anesthesia The goal is to recognize and quickly correct airway obstruction, peaks or troughs in blood pressure, decreases in blood oxygenation, temperature changes and delirium to temper any sudden changes in physiology, to minimize pain, nausea or vomiting, and

15. Characteristics of the patient and the surgery can also prolong the time needed for recovery DURATION OF SURGERY VENTILATION ABILITY PRE-EXISTING MEDICAL PROBLEMS

16. Duration of surgery Longer surgeries build higher concentrations of anesthetic that is stored in tissues throughout the body Patients tend to recover more slowly from longer operations

17. Ventilation ability Gaseous anesthetics are released from the body through the lungs Postoperative patients with poor ventilation take longer to reduce their anesthesia load and these patients require more recovery time

18. Pre-existing medical problems Patients with metabolic or excretory problems, such as liver disease or kidney disease tend to recover more slowly from anesthesia (Morgan et al., 2006)

19. Complications?

20. PAIN MANAGEMENT

21. MANAGEMENT OF PAIN(at PACU ) Assess and record pain and its characteristics: Location Frequency Quality Use pain assessment scale Administer analgesics to promote optimum pain relief

22. commonly used pain rating scales

23. categorical scale or the simple descriptor scale A list of adjectives describing different levels of PAIN INTENSITY no pain mild pain moderate pain severe pain

24. Visual Analogue Scale (VAS) PAIN AS BAD AS IT COULD POSSIBLY BE NO PAIN ________________________ 10 cm (AHCPR 1994)

25. Faces Rating Scale Most commonly used is the : Wong-Baker Faces scale 0-5 or 0-10 scale with 6 facial expressions suggesting different pain intensities each face accompanied by a descriptor and number helpful for assessing persons with moderate to severe dementia who have lost much of their ability to use language to describe pain

26. Wong-Baker FACES Pain Rating Scale WHICH FACE SHOWS HOW MUCH HURT YOU HAVE RIGHT NOW ? 0 1 2 3 4 5 HURTS LITTLE MORE HURTS EVEN MORE HURTS WHOLE LOT HURTS WORST NO HURT HURTS A LITTLE BIT Adopted from Wong DL, Hockenberry-Eaton M. Wilson D. et.al.Whaley & Wong’s Nursing Care of Infants and Children. 6th ed. St. Louis, MO: Mosby-Year Book, Inc. 1999.

27. Pharmacologic approaches to pain management 1. NONOPIOID ANALGESICS 2. OPIOID ANALGESICS

28. NONOPIOID ANALGESICSnonsteroidalantiinflammatory drugs(NSAIDS) Act at the site of tissue injury by blocking the synthesis of prostaglandins that sensitize the nociceptors Example: Aspirin, acetaminophen, ibuprofen ketorolac, ketoprofen

29. Opioid analgesics The most potent analgesics used in the management of moderate to severe pain Binds to opioid receptors in the brain stem

30. Frequently used opioids MORPHINE CODEINE MEPERIDINE FENTANYL

31. COMMON SIDE EFFECTS OF OPIOIDS RESPIRATORY DEPRESSION NAUSEA AND VOMITING SEDATION CONSTIPATION POTENTIAL TO PRODUCE TOLERANCE, DEPENDENCE AND ADDICTION

32. SIGNS AND SYMPTOMS OF NARCOTIC TOXICITY Unresponsiveness to physical stimulation Respiratory rate less than 7 per minute BRADYCARDIA Pinpoint pupils

33. NALOXONE A pure antagonist , used to counteract the effects of a narcotic overdose

34. Respiratory Complications Nearly two thirds of major anesthesia-related incidents may be respiratory. Airway obstruction Hypoxemia Low inspired concentration of oxygen Hypoventilation Areas of low ventilation-to-perfusion ratios Increased intrapulmonary right-to-left shunt

35. Do: Go to see the patient! Assess the patients vital signs and respiratory rate. Evaluate the airway. R/o obstruction or foreign body. Mask ventilate with ambu if necessary. Intubate and secure the airway. Look for causes of hypoxia. Send ABG, CBC, Get CXR. Respiratory Complications

36. Failure to Regain Consciousness Residual anesthetics: IV or inhaled Profound neuromuscular block Profound hypothermia Electrolyte abnormalities Thromboemboliccerebrovascular accident Seizure

37. Myocardial Ischemia Increased risk: History of CAD CHF Smoker HTN Tachycardia Severe hypoxemia Anemia Same risk if the patient has GA or regional anesthesia. Treatment Oxygen, ASA, NTG, and morphine if needed Consult cardiology

38. BLOOD SUGAR ABNORMALITIES Stress of surgery cortisol/glucagon dehydration/SSI Surgery can unmask type 2 diabetes in people with previously undetected disease, so all PACU patients should have their blood glucose levels checked at least once. patients liver disease glycogen hypoglycemia

39. Discharge from PACU A typical PACU stay is approximately an hour When a patient is transferred to a hospital care unit, the PACU nurse provides a comprehensive medical report to that unit. When the patient is being sent home, an adult must assume responsibility for the patient

40. Discharge criteria Unless the patient is going to an ICU, the patient who have had general anesthesia are not discharged from the PACU until he is: Awake and oriented Has clear airways, can breathe autonomously, and is maintaining a satisfactory level of blood oxygenation Has been physiologically stable with acceptable vital signs for 15-30 minutes

41. Is not hypothermic Is not actively bleeding Has controlled and tolerable levels of postoperative pain Is not vomiting (Aldrete, 1998; Smith & Hardy, 2007; Sherwood et al., 2008

42. All patients who have had regional anesthesia are not discharged until the sensory and motor blocks have worn off (Kiekkas et al., 2005; Morgan et al., 2006)

43. Discharge From the PACU Aldrete Score: Simple sum of numerical values assigned to activity, respiration, circulation, consciousness, and oxygen saturation. Postanesthesia 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.

44. Aldrete Score

45. Postanesthesia Discharge Scoring System

46. summary During their recovery from anesthesia, patients must be monitored until they are awake and their vital signs are stable. In an era of complex major surgeries done on increasingly compromised patients, emergence from anesthesia sometimes comes with life-threatening complications. For these reasons, recovery rooms, which were once postsurgical rest stations, are now short-term ICUs called postanesthesia care units, or PACUs.

47. PACU is staffed by nurses who are skilled in recognizing and managing airway problems, hypoxemia, hypotension, hypothermia, pain, nausea, and vomiting, as well as the lingering effects of anesthesia and muscle relaxants. PACU nurses must cope with bleeding from surgical sites, hypertension, dysrhythmias, myocardial infarctions, and altered mental states. The nurses carry out these specialized medical tasks in a setting where, at the same instant, there can be patients who are unconscious, emerging from sedation, suffering from acute respiratory or circulatory complications, being admitted, and being discharged.

48. Frederico A. (2007). Innovations in care: The nurse practitioner in the PACU. Journal of PeriAnesthesia Nursing 22(4): 235–42. American Society of PeriAnesthesia Nurses (ASPAN). (2003a). A position statement for medical-surgical overflow patients in the postanesthesia care unit (PACU) and ambulatory care unit (ACU). Retrieved May 2008 from http://www.aspan.org/PosStmts14.htm. American Society of Anesthesiologists (ASA). (2004). Standards for Postanesthesia Care. Retrieved March 2008 from http://www.asahq.org/publicationsAndServices/sgstoc.htm. Hockenberry MJ, Wilson D, Winkelstein ML: Wong's Essentials of Pediatric Nursing, ed. 7, St. Louis, 2005, p. 1259. Aldrete JA. (1998). Modifications to the postanesthesia score for use in ambulatory surgery. Journal of PeriAnesthesia Nursing 13(3): 148–55. References:

49. Thank you very much for your kind attention...