POST ANESTHESIA CARE UNIT

(PACU)
Department of Anesthesiology &
Reanimation
School of Medicine, Malahayati University/
Abdul Moeloek General Hospital
Bandar Lampung
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Design of PACU
Dekat dg ruang op. & fasilitas ICU lain
Banggsal terbuka (u/ memfasilitasi
observasi dr semua pasien scr bsamaan)
Pencahayaan yg baik (day light)

Equipment

Pulse oxymetri
ECG
BP monitor
Selimut penghangat/pendingin
Emergency trolley
outlets : oxygen, electrical, suction
minor set
infusion/syringe pump
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Before world war II

kematian post op. stlh anestesia &
pembedahan tinggi
periode ini dicirikan o/ insidensi yg scr
potensial mengancam kehidupan yg relatif
tinggi.
Komplikasi respirasi & sirkulasi.
After world war II
Keberhasilan RR faktor dl evaluasi
ICU/PACU

Staffing
Perawat terlatih dlm perawatan pasien
emergensi (ACLS)
- 1 perawat untuk 2 tempat tidur
(pasien)
Arahan/petunjuk medis dari seorang ahli
anestesi dikoordinasikan kpd ahli bedah &
konsultan lain.
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Kedaruratan Anestesia
Karena post.op adl waktu yg membuat srtres
berat.
Ex..
- obstruksi jln nafas
- gemetar (Shivering)u
- Muntah (Vomite) ...etc.
Kedaruratan yg tertunda (Delayed
Emergence)
Ketika pasien gagal u/ kembali sadar dlm
waktu 60-90 menit stlh anestesi umum (G.A.)
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The causes
Residual Anesthetic
Sedative
Perpanjangan efek opiat
Hypothermia
Ggn Metabolic
Perioperative stroke (rare)
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Manajemen Post op/post anesthesia

Monitoring: - tda2 vital

- BP
Pulse/HR
RR

- Suplemen Oxygen (SpO2)

- Temp
- Sensory and motor level
(Regional Anesthesia)
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Kontrol Nyeri
- parenteral
- Regional anesthesia
- Nerve Block
Agitation/Restlessness
- penyebab ? (hipoxemia, acidosis etc)
Mual & muntah
etiologi ? hipotensi karena :
- regional anesthesia
- opioid
- vagal tone
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menggigil
etiologi ?
- Unwarmed I.v. fluids
- Exposure dari luka yg luas
- AC
- Hyperthermia
- Metabolic acidosis ect
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Komplikasi di PACU
1. obstruksi jalan nafas
- pasien tidak sadar lidah terjatuh
ke bagian posterior faring
- spasme laring
- edema glotis etc
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2. Hypoventilation
- didefinisikan sbg PaCO2 > 45 mmHg
pH < 7,25
- etiologi :
efek Residual depressant agen
anestesi (overdose)
pembalikan yg tidak adekuat
sakit yg berat
Tight abdominal dressing
produksi CO2 tinggi
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3. Hipoksemia
didefinisikan sbg PaO2 < 70 mmHg
etiologi :
- Hypoventilation
- Oxygen consumption
- FRC
- Lung - edema
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4. Hipotensi
- didefinisikan sbg 20-30% reduksi
BP
- etiologi :
- Hypovolemia
- Ventricular dysfunction
- Impaired cardiac filling
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5. Hypertension
didefinisikan sbg BP > 20-30% dari
batas bawah (base line)
etiologi :
aktifitas simpatis
- nyeri
- hypercapnia

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6. Arrhythmia
- Hypercarbia
- Ggn Electrolyte
- efek Residual dari inhibitor
cholinesterase

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Discharge criteria
- must be evaluated
- after 60 minutes in the PACU
_____________________________________
Parameters
Value
____________________________________
color - pink
2
- pale
1
- cyanotic
0
_____________________________________
Respiration - Breathe deeply & cough
2
- Shallow but adequate
1
- apnea
2
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_____________________________________

Circulation
BP within 20% of normal
2
20-50%
1
50% from normal
0
________________________________________________
_
Consciousness
- awake/alert
2
- arousable
1
- no response
0
________________________________________________
_
Activity
- move all extr
2
- move 2 extr
1
- no movement
0

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INTENSIVE CARE UNIT (ICU)

- Multi disciplinary
- As intensive care with potentially life
threatening illness
- Supporting therapies
- neurologic
- cardiovascular/hemodynamic
- Pulmonary/respiratory
- Electrolyte/metabolism
- Nutritional
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NEUROLOGIC SUPPORT
- CBF is constant auto regulation
at range of BP (MAP 50150mmHg)
- Injury losses of ability
autoregulation
- CBF related to CPP
(CPP = MAP-ICP)
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ACUTE CNS INJURY

- Ischemia (focal or generalize)
- Structural distortion of brain
- Scoring GCS
- CNS support is focused on
- optimizing systemic & cerebral B.F
- normalizing ICP

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-Immediate concerns
- airway/ventilation/oxygenation
- hemodynamic issues
-Hypotension (loss of automatic control)
- Hypertension (hyper adrenergic state)
- Cardiac dysfunction
- Seizures control (metabolic/infections)
- Neurologic exam
- Is there a surgical lession ?
- GCS
- Laboratory
- CT Scan
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SUPPORTIVE CARE
- General treatment
- Oxygenation
- Correct anemia
- Hemodynamic stability
- Establish normovolemia
- Control hyperthermia
- Control seizures
- control pain
- Avoid agitation/shivering
- correct metabolic abnormalities
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-Control ICP
- CSF (volume reduction)
- Hyperventilation
- Osmotic agent
- Barbiturate
- Head position
- To be prevent vasospasm
- Steroid (?)

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CARDIOVASCULAR/HEMODYNAMIC
SUPPORT
-Major determinants of cardiac output (C.O)
- Heart rate & Contractility
- Blood Vessels
- Volume Intra vascular
- Pre Load
- After Load
- Oxygen Delivery
- C O = HR x 3 V

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SV Is Determined By
- Preload
- After load
- Contractility
* Clinical Measurements
- Preload - Echo Cardiography
- PCWP
After load = SVR
= MAF - CV x 80
C. O
Contractility = ECHO = EF
*

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Oxygen Delivery (D O2)

D O2 = Ca O2 x C O x 10
= (HB x 1.34 x Sa O2)
+(PaO2 x 0,031) x C. O x 10

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SHOCK
*
*

Characterized BV
- Organ Blood Flow that Is Inadequate
to meet Tissue Demands
Four Categories Of Shock
1. Cardiogenic Shock
- Co
- PCWP
- SVR
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2. Hypovolemic Shock
- CO
- PCWP
- SVR
3. Distributive Shock
- CO
N/
- PCWP N /
- SVR
4. Obstructive Shock
- CO
- PCWP
-SVR
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MANAGEMENT OF SHOCK
- Increasing C.O
- Therapy Arrhythmias
- To Manage - Pre Load
- After Load
- Fluid
- Improve Contractility
- Optimize Oxygen Delivery
- Hemoglobin
- P a O2 (FiO2 & Lung Function)
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- Vaso Pressor & Inotropic Agent

- Dopamine. etc
- Antibiotic
- Decrease Oxygen Demand

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Respiratory Support
One of Most Common Disorder Leading to 1cm
Admission is ARF (Acute Respiratory Failure)
ARF. - When the Pulmonary system is no
longer able to meet the metabolic
demands of the body
Two types of respiratory failure (RF)
Type I Hypoxemic RF (PaO2 50TORR)
Type II Hypercapmic RF (PaCO2 50 TORR)
- with hypoxemic
- without hypoxemic
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Causes of RF
Type I (Usually the result of mismatch of
alveolar ventilation and pulmonary
perfusion)
Example - Acute lung injury
- Acute pulmonary edema
Type II (Characterized by alveolar
hypoventilation)
Example - Airflow obstruction
- CNS
- Neuromuscular disturbances
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CLINICAL MANIFESTATIONS OF ARF

IS ARDS
- Onset 12-72 hours after triggers
- Respiratory distress (gasping, cyanotic etc)
- Lung edema (non cardiogenic)
- PaO2 < 50mmHg
- CPWP > 18mmHg
- PaO2/FiO2 < 200mmHg
Management
- Oxygen supplement
- nasal canula
- face mask
- IPPV non invasive
- Pharmacologic
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ELECTROLYTE DISTURBANCES
Es the most common disturbances are in K+
Na+ Ca+
A. Potassium (N.3,5-5,5 mEq/L)
1. Hypokalemia (K+ < 3,5 mEq/L)
Causes
- Renal & extra renal losses
- Transcellular shift
- Decreased intake
Clinical
- Arrhythmias
- ECG. Abnormalities
- Muscle Weakness
- Ileus Etc.
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TREATMENT
- Correcting The Underlying Cause
- Stop Offending Drubs
- Correct The Potassium level
- K + > 3 Meg /L . KCL 20-40 Meg/4-6
MRS . Orally/NGT
- K + <2,5 Meg /L KCL 20-30 Meg
/HRS Intravenously

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2. HYPERKALEMIK ( K+>5,5 mEq/L

- Most often from renal dysfunction
- Other Causes
- Acidemia
- Hypoaldosteronism
- Cell Death (Hemolysis,
Burnsetc)
- Excessive Intake
Clinical - Arrhythmias
- Muscle Weakness
- Paralysis. etc.
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TREATMENT
- Underlying cause
- Stop Offending Drugs
- Limitation of Potassium
- Correcting
- ECG Abnormalities are present
- CaCl2 10 % 5-10 ml (i.v.5-10 mnt)
- Sodium Bicarbonate
1 Meg /Kg BW /I.V 5-10 mnt.
- 10 IU RI. In 10 Ml Dext.50 %/IV/10
- Dialysis
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3. SODIUM (N 135 - 145 mEq/L)

1. Hyponatremia (Na + < 135 mEq/L)
Causes
- Excess Secretion of ADH
- Non Sodium Solute Infusion
Clinical.
- CNS Disturbances
- Muscular Disturbances

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TREATMENT
- Treating the Underlying Disease
- Stop Offending Drugs
- Correcting
- Restricting free water intake
- Increasing free water clearing
- Loop diuretic
- Replace with saline 5 %
- Limit 15 mEq/L in first 24
hours
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2. HYPERNATREMI (Na + > 145 mEq/L)

Cause - Intracellular volume Depletion
with
- A Loss of free water
- Excessive sodium intake
Clinical
- CNS
- Muscle
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TREATMENT
Underlying Causes
Free water Repletion
L
= 0,6 x wt [( Na1 /Na2)-1]
L
= Water deficit
Na 1 = Normal Sodium Level
Na 2 = Measured
Wt = KS
- Correcting . 12-20 Meg /C/24HRS
- Dialysis
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METABOLIC DISTURBANCES
Hyperglycemic Syndromes
- Life Threatening Hyperglycemic syndrome
1. Diabetic Ketoacidosis (DKA)
2. Hyperglycemic Hyperosmolar Nonketotic
syndrome (H1 + NK)
Clinical
- Osmotic Diuresis Dehydration
- Weakness
- CNS Manifestation
- Odor to the Breath
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TREATMENT
- The Goals are
- Restore the Fluid & Electrolyte Balance
- Provide Insulin
- Identify Precipitating Factor
- NS. 20 ml/ kg for First Hour
Then. 250-500 ml/Hr AS Needed
After that
- NS 0,5 % Maintenance
- Insulin (R1) 5-10 IU
Followed By 5-10 IU /HR. (0,1 IU /kg/HR)
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IF Glucose Level 250 Mg %

- Glucose Containing Fluid (1/V)
(Maintain Glucose level >150
By Insulin S.C.
IF Glucose Level < 150 mg %
- Glucose 10 %
IF PH < 7.0
- Consider Bicarbonate
- Correcting the Serum level (if Present)
- Potasium
- Phosphorus
- Magnesium
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