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Postanesthesia Care

Muhamad Chairul Fadhil

Pembimbing : dr. Hj. Dwiana Sulistyanti, Sp.An-KAO


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
KEYNOTES
• POSTANESTHETISIA CARE UNIT
• EMERGENCE FROM GENERAL ANESTHESIA
• TRANSPORTING THE PATIENT FROM OR TO TO THE PACU
• ROUTINE RECOVERY
• MANAGEMENT COMPLICATION
• DISCHARGE CRITERIA
The Postanesthesia Care Unit
(PACU)
• DESIGN
• EQUIPMENT
• STAFFING
Design
Size:
• Ideal ratio 1.5 PACU bed for every Operating Room
• 120 square foot per patient
• Minimum of 7 feet between beds
Facilities:
• Piped Oxygen, Vacuum and Air
• Multiple electrical outlets
• Large doors
• Good lighting
• Isolation for Immuno-compromised patients
Equipment
• Multi-parametric monitors (Automated NIBP, pulse oximetry, 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.
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.
Emergence from General Anesthesia
• Recovery from general or regional anesthesia is a time of great
physiological stress, should ideally be characterized by a smooth and
gradual awakening in a controlled environment.
• Following an inhalational-based anesthetic, the speed of emergence
is directly proportional to alveolar ventilation, but inversely
proportional to the agent’s blood solubility
• Emergence from an intravenous anesthetic is a function of its
pharmacokinetics.
• The speed of emergence can also be influenced by preoperative
medications.
Delayed Emergence
• The most frequent cause of delayed emergence (when the patient
fails to regain consciousness 30–60 min after general anesthesia) is
residual anesthetic, sedative, and analgesic drug effect.
• Naloxone (in 80 mcg increments in adults) and flumazenil (in 0.2 mg
increments in adults) will readily reverse the effects of an opioid and
benzodiazepine, respectively. Physostigmine (1–2 mg) may partially
reverse the effect of other agents.
Transport From the OR to the PACU
Criteria for shifting from OR to PACU
• Haemodynamic stablity
• Clinical evaluation and complete recovery from NM blockade
• Maintenance of Oxygen saturation
• Normothermia
Routine Recovery
• General Anesthesia
• Regional Anesthesia
• Pain Control
• Agitation
• Nausea and Vomiting
• Shivering and Hypothermia
General Anesthesia
• Assessed for airway patency, vital sign, oxygenation, level of
consciousness
• Vital sign every 5 minutes for 15 minutes or until stable
• Additional monitoring include pain assessment, nausea and vomiting,
fluid input and output
• Report to the PACU nurse that includes :
• The preoperative history
• Pertinent intraoperative events
• Expected postoperative problems
• Anticipated need for PACU medication
• Postanesthesia orders
Regional Anesthesia
• Patients who are heavily sedated or hemodynamically unstable
following regional anesthesia should also receive supplemental
oxygen in the PACU.
• Sensory and motor levels should be periodically recorded following
regional anesthesia to document regression of the block.
• Blood pressure should be closely monitored following spinal and
epidural anesthesia.
• Bladder catheterization may be necessary in patients who have had
spinal or epidural anesthesia for longer than 4 hr.
Pain Control
• Mild to moderate postoperative pain can be treated orally with
acetaminophen, ibuprofen, hydrocodone, or oxycodone.
• Moderate to severe postoperative pain is most commonly treated
with oral or parenteral opioids.
• Alternatively, ketorolac tromethamine (15–30 mg in adults) or
acetaminophen (15 mg/kg, or 1 g if patient >50 kg) may be
administered intravenously.
• Opioids of intermediate to long duration, such as hydromorphone
0.25–0.5 mg (0.015–0.02 mg/kg in children) or morphine 2–4 mg
(0.025–0.05 mg/kg in children), are most commonly used.
Agitation
• Before the recovering patient is fully responsive, pain is often
manifested as postoperative restlessness.
• Serious systemic disturbances (such as hypoxemia, respiratory or
metabolic acidosis, or hypotension), bladder distention, or a surgical
complication (such as occult intraabdominal hemorrhage) must also
be considered in the diff erential diagnosis of postoperative agitation.
• If serious systemic disturbances and pain are excluded, persistent
agitation may require sedation with intermittent intravenous doses of
midazolam 0.5–1 mg (0.05 mg/kg in children).
Risk factor for postoperative nausea and vomiting
Nausea and Vomiting
• Postoperative nausea and
vomiting (PONV) is common
following general anesthesia,
occurring in 30% to 40% of all
patients
• Selective 5-hydroxytryptamine(serotonin) receptor 3 (5-HT 3 )
antagonists, such as ondansetron 4 mg (0.1 mg/kg in children), are eff
ective in preventing PONV, and, to a lesser extent, in treating
established PONV. Metoclopramide 0.15 mg/kg intravenously, is a less
effective alternative to 5-HT 3 antagonists.
• Dexamethasone 4–10 mg (0.10 mg/kg in children), when utilized as
an antiemetic, has the additional advantages of providing a varying
degree of analgesia and a sense of patient well-being.
Shivering and Hypothermia
• Hypothermia should be treated with a forced-air warming device, or
(less satisfactorily) with warming lights or heating blankets, to raise
body temperature to normal.
• Small intravenous doses of meperidine (10–25 mg) can dramatically
reduce or even stop shivering. Intubated and mechanically ventilated
patients can also be sedated and given a muscle relaxant until
normothermia is reestablished by active rewarming and the eff ects
of anesthesia have dissipated.
Management Complication
• Respiratory Complication
• Airway Obstruction
• Hypoventilation
• Hypoxemia

• Circulatory Complication
• Hypotension
• Hypertension
• Arrythmias
Respiratory Complications
• Airway Obstruction:
– Sagging tongue: Treated with triple maneuver
• Laryngeal Spasm:
– Due to secretions
– Due to irritable airways (smokers)
• Rx: 100% Oxygen through face mask
• Hydrocoritsone 100 mg IV
• If no improvement rapid intubation to secure the airway
Hypoventilation
• Hypoventilation in the PACU is most commonly due to the residual
depressant effects of anesthetics on respiratory drive.
• Treatment should generally be directed at the underlying cause, but
marked hypoventilation always requires assisted or controlled
ventilation until causal factors are identified and corrected.
Hypoxemia
• Mild to moderate hypoxemia (Pa o 2 50–60 mmHg) in young healthy
patients may be well tolerated initially, but with increasing duration
or severity, the initial sympathetic stimulation often seen is replaced
with progressive acidosis and circulatory depression.
• Pulse oximetry facilitates early detection of hypoxemia and must be
routinely utilized in the PACU. Arterial blood gas measurements may
be performed to confi rm the diagnosis and guide therapy.
• Oxygen therapy with or without positive airway pressure is the
cornerstone of treatment for hypoxemia.
Circulatory Complications:
• Hypotension: • Arrythmias:
• Decreased preload • Electrolyte imbalance ( K )
• Decreased myocardial contractility • Hypoxia
• Increased after load • Hypercarbia
• Hypertension: • Metabolic acidosis
• Pain
• Hypercapnia
• Hypothermia
• Hypoxemia
• Excess Intra vascular volume
• Pre-existing hypertension
Discharge Criteria
• 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)
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 (PADS):


• 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.
Aldrete score
Post-anesthesia Discharge Scoring System (PADS)
THANK YOU