Post anesthesia care unit management

1. saneeshpj@yahoo.com
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2. Postanesthesia Care Unit
• The PACU is designed and staffed to
monitor and care for patients who are
recovering from the immediate physiologic
effects of anesthesia and surgery
resuscitate patients
who are unstable
provide a tranquil
environment for the
“recovery” and
comfort of patients
who are stable

3. PACU
• Specially trained nurses skilled in the
prompt recognition of postoperative
complications make up the staff of the
PACU
• On arrival of a patient to the PACU, the
anesthesiologist provides the PACU nurse
with pertinent details of the patient’s
history, medical condition, anesthesia, and
surgery

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

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

6. Standards of PACU
• All patients who have received general
anesthesia, regional anesthesia or
monitored anesthesia care shall receive
appropriate postanesthesia management

7. Standards of PACU
• A patient transported to the PACU shall be
accompanied by a member of the
anesthesia care team who is
knowledgeable about the patient’s
condition
• The patient shall be continually evaluated
and treated during transport with
monitoring and support appropriate to the
patient’s condition

8. Standards of PACU
• Upon arrival in the PACU, the patient shall
be re- evaluated and a verbal report
provided to the responsible PACU nurse
by the member of the anesthesia care
team who accompanies the patient.

9. Standards of PACU
• The patient’s condition shall be evaluated
continually in the PACU. The patient shall
be observed and monitored by methods
appropriate to the patient’s medical
condition.

10. Standards of PACU
• A physician is responsible for the
discharge of the patient from PACU
• Multiple antiemetic agents are used for the
prevention or treatment of postoperative
nausea and vomiting (PONV).
• Oxygen is administered for patients at risk
of hypoxemia.

11. Standards of PACU
• When available, forced air warmers should
be used to reach the goal of
normothermia.
• Demerol or other opioid agonists should
be used for the treatment of postoperative
shivering but not replace treating
hypothermia by rewarming.

12. Standards of PACU
• Specific antagonists should be available
whenever benzodiazepines, opioids, or
neuromuscular blockers have been
administered.
• A mandatory minimum stay should not be
required, but patients should be observed
until they are no longer at risk for
cardiopulmonary depression.

14. Assessment & Monitoring

15. Assessment & Monitoring

16. PACU “incidents”

18. Complications in PACU
23.7%

20. PONV
• Without prophylactic intervention,
approximately one third of patients who
undergo inhalational anesthesia will
develop PONV (range, 10% to 80%)
• From a patient’s perspective, PONV may
be more uncomfortable than postoperative
pain.

21. PONV
delayed discharge from the PACU
unanticipated hospital admission
increased incidence of pulmonary
aspiration
significant postoperative discomfort

22. Antiemetic Drugs

23. Antiemetic Drugs

24. PONV
• Although prophylactic measures to prevent
PONV are more effective than rescue, a
subset of patients will require treatment in
the PACU even after appropriate
prophylactic treatment.

25. PONV
• If an adequate dose of antiemetic
medication given at the appropriate time is
ineffective, then simply giving more of the
same class of drug in the PACU is unlikely
to be of significant benefit.

27. Upper Airway Obstruction
• Loss of pharyngeal muscle tone
• Residual NM blockade
• Laryngospasm
• Airway edema/hematoma
• Obstructive Sleep Apnea (OSA)

28. Upper Airway Obstruction

29. Upper Airway Obstruction
• An obstructed upper airway requires
immediate attention.
• Efforts to open the airway by noninvasive
measures should be attempted before
reintubation.

30. Upper Airway Obstruction
Jaw thrust +/-CPAP
Oral/Nasal airway;
LMA
Tracheal intubation

31. Upper Airway Obstruction
• The cause of the upper airway obstruction
should be identified and treated
• Sedating effects of opioids and
benzodiazepines can be reversed with
persistent stimulation or small, titrated
doses of naloxone (0.3 to 0.5 μg/kg IV) or
flumazenil (0.2 mg IV to maximum dose of
1 mg), respectively.

32. Upper Airway Obstruction
• Residual effects of neuromuscular
blocking drugs can be reversed
pharmacologically or by correcting
contributing factors such as hypothermia

34. Postop Hypoxemia
• Right-to-left intrapulmonary shunt (atelectasis)
• Mismatching of ventilation to perfusion
(decreased functional residual capacity)
• Congestive heart failure
• Pulmonary edema (fluid overload,
postobstructive edema)
• Alveolar hypoventilation (residual effects of
anesthetics and/or neuromuscular blocking
drugs)

35. Postop Hypoxemia
• Diffusion hypoxia (unlikely if receiving
supplemental oxygen)
• Inhalation of gastric contents (aspiration)
• Pulmonary embolus
• Pneumothorax
• Increased oxygen consumption (shivering)

36. Postop Hypoxemia
• Sepsis
• Transfusion-related lung injury
• Adult respiratory distress syndrome
• Advanced age
• Obesity

37. Pulmonary Edema
• Pulmonary edema in the immediate
postoperative period is often cardiogenic
in nature
– intravascular volume overload
– congestive heart failure
• Less frequently, pulmonary edema may
result from airway obstruction
(postobstructive pulmonary edema),
sepsis, or transfusion

38. Pulmonary Edema

39. Postobstructive Pulmonary
Edema
forced inspiration against an
obstructed airway
large negative intrathoracic
pressure
increase in pulmonary vascular
volume and pulmonary
capillary transmural pressure
risk of disruption of the
alveolar–capillary membrane

40. Postobstructive Pulmonary
Edema
• Relief of the airway
obstruction
• Correction of hypoxemia
• Addressing pulmonary
edema

41. Postobstructive Pulmonary
Edema
• Persistent airway obstruction may
necessitate an artificial airway, and acute
respiratory failure would require artificial
ventilation with oxygen and appropriate
levels of PEEP.
• A longer period of observation in PACU.

42. Postobstructive Pulmonary
Edema
• With prompt diagnosis and therapeutic
action, NPPE resolves generally within 24
hr.
• However, when recognition is delayed,
patients with NPPE have mortality rates
ranging from 11% to 40%.
• A high index of suspicion - postextubation
laryngospasm…..

44. Hypertension in PACU

46. Hypotension in PACU

47. Hypotension in PACU

48. Hypotension in PACU

50. MI in PACU
• High risk patients
• ST-segment and T-wave changes on the
ECG
• Determination of serum troponin levels
• 12-lead ECG
• Cardiology follow up

51. Cardiac dysrhythmias
Tachycardia
Bradycardia
Arrhythmias –
ventricular/supraventricular

53. Periop Anaphylaxis

55. Postoperative shivering
• Usually, but not always, associated with
hypothermia
• Accurate core body temperatures can be
most easily obtained at the tympanic
membrane

56. Postoperative shivering
Forced air
warmers
Opioids
Ondansetrone
Clonidine

58. Delirium
• Approximately 10% of patients older than
50 years of age who undergo elective
surgery will experience some degree of
postoperative delirium within the first 5
postoperative days

59. Delirium
• Risk factors
– Elderly (70 yrs or older)
– Preop cognitive impairment
– Decreased functional status
– Alcohol abuse
– H/o delirium

60. Emergence Excitement
• Atransient confusional state that is
associated with emergence from general
anesthesia.
• Emergence excitement is common in
children, with more than 30% experiencing
agitation or delirium at some period during
their PACU stay.

61. Emergence Excitement
• Usually occurs within the first 10 minutes
of recovery
• Typically resolves quickly and is followed
by an uneventful recovery
• In children, emergence excitement is most
frequently associated with rapid “wake up”
from inhalational anesthesia.

62. Discharge
from PACU