Clinical Problems in the Postanesthesia Recovery Room (PACU)

1
Clinical Problems in the Postanesthesia
Recovery Room (PACU)

• Heidi Eriksson, MD, PhD
• Helsinki University Central Hospital
• Finland

2
Recovery room incidents a review of 419 reports
from the Anaesthetic Incident Monitoring Study
(AIMS) Kluger and Bullock Anaesthesia 2002

• The Australian incident monitoring study
  (Anesthesia and Intensive Care 1993)
• incident reporting study
• voluntary, self-reporting audit of
  actua/potential incidents that occur during
  anesthesia
• 8372 reports , 478(18) in PACU

3
Recovery room incidents a review of 419 reports
from the Anaesthetic Incident Monitoring Study
(AIMS)

• 92 in adults
• 90 during daytime hours
• 4 at night

Kluger and Bullock. Anaesthesia 2002
4
Factors influencing stay in the postanesthesia
care unit
Seago J et al. J Clin Anaesth 1998

• Patient history and age were not predictive!
• Postoperative pulmonary/airway problems
• desaturation, stridor, obstruction
• Postoperative cardiovascular problems
• hypo/hypertension, chest pain/ECG changes,
  pulmonary oedema/HF
• Length of surgery
• Unexplained - due to organizational factors ??

5
American Society of Anesthesiologists-Physical
Status Classification(ASA-PS)

• is not an indicator of perioperative risk
• Perioperative risk
• preoperative medical status
• nature on the anesthetic technique
• nature of the surgical procedure
• low risk- intermediate risk-
  high risk
• does not take into account
• age
• complexity of the operation
• is a measure of preoperative medical status

6
Preoperative assessment
7
Type of procedure recovery room incidents
reported to AIMS

• General surgery 118 28
• Orthopedics 72 17
• Ear, nose and throat 42 10
• Opthalmology 33 8
• Gynecology 30 7
• Urology 28 7
• Vascular 25 6
• Dental and maxillofacial 14 3
• Plastic 12 3
• Cardiothoracic 12 3
• Obstetric 10 2
• Electroconvulsive 6 1
• Neurosurgery 5 1
• Pain block 2 0.5
• Radiology 1 0.2
• Vascular access 1 0.2

Kluger and Bullock. Anaesthesia 2002
8
Primary presenting problem recovery room
incidentsreported to AIMS

• Cardiovascular 99 24
• Respiratory 97 25
• Airway 86 21
• Drug error 44 11
• CNS 32 8
• Equipment 27 6
• Communication problems 7 2
• Hypotermia 6 1
• Regional block problems 4 1
• Inadequate documentation 4 1
• Hyperthermia 3 1
• Trauma 3 1
• Dental problems 2 0.5
• Renal 1 0.2
• Skin 1 0.2
• Blood transfusion 1 0.2
• Facility limitations 1 0.2
• Gastrointestinal problems 1 0.2

Kluger and Bullock. Anaesthesia 2002
9
Presenting problem in 99 cardiovascular incidents
out of 419 PACU incidents reported to AIMS

• Pulmonary oedema 29 7
• Hypotension 26 6
• Cardiac arrest 20 5
• Bradycardia 7 2
• Myocardial ischemia 7 2
• Tachycardia 4 1
• Bleeding 2 0.5
• Hypertension 2 0.5
• Allergy 1 0.2
• Radial artery ischemia 1 0.2

Kluger and Bullock. Anaesthesia 2002
10
Hypotension in PACUQuick assessment

• decreased ventricular preload
• hypovolaemia
• postoperative bleeding
• reduced myocardial contractility
• myocardial ischemia
• congestive heart failure
• reduction of systemic vascular resistance
• septicaemia
• regional anesthesia/analgesia
• anaphylaxis

11
Hypertension in PACUQuick assessment

• pain
• hypoxia
• hypercapnia
• anxiety/agitation
• fluid overload
• developing pulmonary oedema
• urinary retention
• untreated hypertension

12
Heart rhytm abnormalities in PACUQuick assessment

• pain
• hypoxia
• hypercapnia
• hypovolaemia/hypervolaemia
• electrolyte inbalance
• metabolic acidosis
• pre-existing heart disease
• myocardial ischemia

13
Presenting problem in 97 respiratory incidents
out of 419 PACU incidents reported to AIMS

• Respiratory failure inadequate
  oxygenation/ventilation 74 18
• Aspiraton 7 2
• Respiratory arrest 6 1
• Bronchospasm 5 1
• Pneumothorax 5 1

Kluger and Bullock. Anaesthesia 2002
14
Presenting problem in 97 airway incidents out of
419 PACU incidents reported to AIMS

• Airway obstruction 59 14
• Laryngospasm 18 4
• Jaw dislocation 2 0.5
• Foreign body (throat pack) 2 0.5
• Failed extubation 1 0.2
• Endobronchial intubation 1 0.2

Kluger and Bullock. Anaesthesia 2002
15
Desaturation in PACUQuick assessment

• airway obstruction
• laryngeal spasm
• bronchospasm
• hypoventilation
• obesity
• perfusion-ventilation
• atelectasis
• pulmonary oedema
• pneumothorax
• pulmonary embolism
• aspiration
• pain

16
Hypoventilation in PACUQuick assessment

• oversedation
• residual anesthetic
• opioids
• parenteral
• epidural/intrathecal

17
Wheezing in PACUQuick assessment

• laryngeal spasm (stridor)
• after thyroid operation
• bleeding
• paresis of n recurrens
• bronchospasm
• asthma
• bronchial hyper-responsivess (smoking, postviral)
  
• pulmonary oedema
• aspiration
• anaphylaxis

18
But does residual neuromuscular block put our
patients in danger?

• Muscle function and coordination of protective
  reflexes of the pharynx and upper esofagus
  recover late
• Eriksson L et al. Anesthesiology 1997
• Ventilatory response to hypoxia is reduced
  (direct inhibition of chemoreceptor activity in
  the carotic bodies)
• Eriksson L et al. Anesthesiology 1993, Wyon N et
  al Anesthesiology 1999
• Volunteers
• Difficulty in maintaining airway
• Desaturation and need for supplemental oxygen
• Disability to swallow
• Distress
• PACU time prolonged
• Murphy et al. Anesth Analg 2004

Eikerman et al. Anestehsiology 2003 Kopman A et
al. Anesthesiology 1997 Bissinger et al. Physiol
Res 2000
19
Residual neuromuscular block is a risk factor for
postoperative pulmonary complications A
prospective, randomised, and blinded study of
postoperative pulmonary complications after
atracurium, vecuronium and pancuroniumBerg et
al. Acta Anaesthesiol Scand 1997

• Manual TOF during operation
• TOF 1-2/4
• Reversal when 2-4/4
• Extubation when 4/4
• Mechanomyographically postoperatively
• Follow-up up to 6 PODs
• Postoperative pulmonary complication pneumonic
  infiltration/atelectasis in X-ray

20
TOF recordings at first postoperative
mechanomyographic recording
Berg et al. Acta Anaesthesiol Scand 1997
21
Postoperative pulmonary complications
Berg et al. Acta Anaesthesiol Scand 1997
22
Type of surgery and the risk of pulmonary
complications
Berg et al. Acta Anaesthesiol Scand 1997
23
Probability of postoperative pulmonary
complications
Berg et al. Acta Anaesthesiol Scand 1997
Multiple logistic regression analysis relating
the probability of POPC to various covariates
24
Residual paralysis in the PACU after single
intubating dose of nondepolarizing muscle
relaxant with an intermediate duration of action
Debaene et al Anesthesiology 2003

• 526 patients
• 2ED95 dose of vecuronium, rocuronium, or
  atracurium
• No muscle relaxant thereafter
• Excluded, if reversal used
• Time delay between the injection of muscle
  relaxant and quantitative measurement of
  neuromuscular blockade assessed

25

• Conclusion A long duration between the
  administration of a single dose of an
  internediate-acting nondepolarizing muscle
  relaxant and the arrival to PACU does not
  guarantee the lack of residual paralysis
• Note!
• hypothermia,
• halogenated anesthesia agents

Bedaene et al. Anesthesiology 2003
26
Residual neuromuscular block

• Widely used tests to assess recovery from
  neuromuscular block
• Train-of-four ratio gt 0.7 / 0.9 by peripheral
  nerve stimulation
• Reliable clinical tests of postoperative
  neuromuscular recovery
• Sustained head lift fot 5s
• Sustained leg lift fot 5 s
• Sustained hand grip for 5 s
• Sustained tongue depressor test
• Maximun ispiratory presuure gt-50 cm H20
• However,
• poor sensitivity
• do not secure against residual block !

Pedersen et al. Anesthesiology 1990 Shorten et
al. Can J Anaesth 1995 Fruergaard et al. Acta
Anaesthesiol Scand 1998 Bedaene et al.
Anesthesiology 2003
27
Residual neuromuscular block

• Significant residual block can be excluded only
  by objective, methods
• mechanomyography
• electromyography
• acceleromyography
• It is time to move from discussion to action and
  introduce objective neuromuscular monitoring to
  all ORs. I believe that objective neuromuscular
  monitoring is an evidence-based practice and
  should consequently be used whenever a
  nondepolarizing neuromuscular blocking agent is
  administered

Eriksson L. Evidence-based practise and
neuromuscular monitoring. It,s time for routine
quantitative assessment. Anesthesiology 2003
28
The ideal world is one thing, and the real world
another!
Viby-Mogensen. Postoperative residual
curarization and evidence-based anaesthesia. BJA
2000
29
How to avoid residual neuromuscular block? (I)

• Long acting neuronuscular blocking agents should
  not be used
• Antagonize the block at the end of the procedure
• Reversal initiated only when (2-)3-4/4 TOF
  stimulations present or when spontaneous muscle
  activity is present
• Prefer tactile evaluation of response to
  double-burst stimulation (DBS) to TOF stimulation
• Consider clinical signs and symptoms in relation
  to the response to nerve stimulation
• Keep in mind the additive/prolonged effects
  caused by anesthetics and hypothermia

Viby-Mogensen. Postoperative residual
curarization and evidence-based anaesthesia. BJA
2000
30
How to avoid residual neuromuscular block? (II)

• Every operating room and PACU should have an
  apparatus for assessing neoromuscular blockade (
  and know how to use it !)
• TOF, preferably quantitative, monitoring of the
  neuromuscular block is mandatory if antagonists
  are not used!!
• TOF gt0.9 the new gold standard for full
  recovery

Viby-Mogensen. Postoperative residual
curarization and evidence-based anaesthesia. BJA
2000
31
Postoperative pain

• a complication itself ?
• aggressive pain prophylaxis in all patients
• Note!
• pain must be in proportion to the operative
  procedure performed
• operative/postoperative complication in
  development
• tolerance to opioids

32
Postoperative pain

• discomfort
• agitation
• PONV
• sympathetic activation
• cardiovascular complications
• hypertension
• surgical bleeding
• immobilisation
• deep vein thrombosis
• pulmonary dysfunction
• chronic postsurgical pain

33
Opioid related side effects

• PONV
• drowsiness
• respiratory depression
• dysphoria/agitation
• gastrointestinal and bladder dysfunction

34
Balanced or multimodal analgesia

• Non-steroidal anti-inflammatory analgesics
  (NSAIDs)
• Paracetamol
• Local anesthetics
• wound infiltration /neural blockade
• liposome local anesthetics in the future?
• Combined with
• PCA
• Epidural

35
Cyclooxygenase-2 inhibitors in postoperative pain
management. Currest evidence and future
directionsGilron et al. Anesthesiology 2003
36
Efficacy of postoperative epidural analgesia. A
meta analysisBlock et al JAMA 2003

• 1404 articles in PubMed reviewed of which 1304
  rejected
• Inclusion criteria
• randomization
• epidural analgesia versus parenteral opioids in
  adults
• VAS/Numeric rating

37
Efficacy of postoperative epidural analgesia
pain at rest
Block et al. JAMA 2003
38
Efficacy of postoperative epidural analgesia
incident pain
Block et al. JAMA 2003
39
Efficacy of postoperative epidural analgesia
VAS recordings
Conclusion Epidural analgesia (other than TEA
with opioids only) provides better postoperative
analgesia to parenteral opioid
Block et al. JAMA 2003
40
Efficacy of postoperative epidural analgesia
complications
Block et al. JAMA 2003
41
The Little big problem of anesthesiaPostoperati
ve nausea and vomiting (PONV)

• Patient-specific risk factors
• Female sex IA
• Nonsmoking status IVA
• History of PONV/Motion sickness IVA
• Anesthetic risk factors
• Use of volatile anesthetics IA
• Nitrous oxide IIA
• Use of intraoperative IIA and postoperative
  opioids IVA
• Surgical risk factors
• Duration of surgery IVA
• Type of surgery (laparoscopy, ear-nose-throat,
  neurosurgery, breast, strabismus, laparotomy,
  plastic IVB

Consensus guidelines for managing postoperative
nausea and vomiting Gan et al. Anesth Analg 2003
42
Postoperative nausea and vomiting (PONV)Keep the
baseline risk low !

• Regional anesthesia IIIA
• Propofol for induction and maintenence IA
• Intraoperative supplemental oxygen IIIB
• Adequate hydration IIIA
• Avoid nitrous oxide IIA
• Avoid volatile anesthetics IA
• Minimize intraoperative IIA and postoperative IVA
  opioids
• Minimization of neostigmine IIA

Gan et al. Anesth Analg 2003
43
Algorithm for prevention of PONV
Gan et al. Anesth Analg 2003
Multimodal or balanced antiemetic strategy
44
Prophylaxis of PONVAntiemetic doses and timing
in adults
Gan et al. Anesth Analg 2003
45
Treatment of PONV in PACU
Gan et al. Anesth Analg 2003
46
Perioperative mild hypothermia (34-35C)Complicat
ions
Sessler.Perioperative hypothermia. NEJM 1997
47
Perioperative maintenance of normothermia reduces
the incidence of morbid cardiac events A
randomized clinical trial. Frank et al. JAMA 1997
48
Perioperative hypothermia and PACU

• cardiovascular complications
• symphathetic overactivity
• norepinephrine
• coagulapathy
• platelet function
• clotting factor enzyme function
• fibrinolytic activity
• shivering
• increased total-body oxygen consumption
• patient discomfort
• residual neuromuscular blockade
• respiratory complications
• aspiration
• prolongation of PACU stay

49
Perioperative hypothermia

• First stage
• internal transfer of core heat to periphery i.e.,
  internal redistribution
• Second stage
• drop in core temperature as the result of heat
  losses
• cutaneous,
• exposure of viscera
• cold solutions
• Third stage
• cutaneous vasocontriction
• core temperature remains almost stable but the
  heat content of the limbs continues to fall
• Mild hypothermia 34-35 C Sessler Anesthesiology
  2001

50
Perioperative mild hypothermiaDelay in recovery
Lenhard et al.Mild intraoperative hypothermia
prolongs postoperative recivery Anesthesiology
2001
51
Postanesthesia shivering

• Involuntary movement that may affect one/several
  muscle groups and generally occurs in the early
  recovery phase after general anesthesia
• Thermoregulatory shivering
• associated with cutaneous vasoconstriction
• physiological response to hypothermia
• Non-thermoregulatory shivering
• Overall incidence 6-66

52
Risk factors for postanesthesia shivering

• Young adult
• Long surgery anesthesia
• Drop in body temperature
• No active perioperative rewarming
• Anesthetic used
• Halogenated agents
• Thiopental
• Propofol -
• Little opioids perioperatively
• Postoperative pain

53
Hypothermia and shivering in PACU

• Use forced-air blankets and warmed iv solutions
• Consider rewarming the patient before extubation
• Temperature monitoring
• Beware of altered pharmacokinetics
• monitor (and antagonize) residual neuromuscular
  blockade
• extubate when awake ! Increased risk of
  aspiration
• Treat postoperative pain promptly!

Alfonsi. Postanesthetic shivering. Systematic
review. Drugs 2001
54
Postanesthesia shivering Medical treatment
Meperidine 0.4-0.85 mg/kg i.v. Tramadol 1-2
mg/kg i.v. Mg-sulphate 30 mg/kg i.v. (Clonidine
0.3mg/kg i.v)
Alfonsi. Postanesthetic shivering. Systematic
review. Drugs 2001
55
Postoperative agitation

• Hypoxia
• Hypercapnia
• Pain
• Distension of the stomach
• Urinary retention
• Apprehension about the findings at operation or
  fear of pain
• (Intraoperative awareness)
• (Neurological sequalae)

56
Drug error related incidents out of 419 PACU
incidents reported to AIMS

• Inapproriate drug 17 4
• Overdosage 14 3
• Inadequate drug/dosage 6 1
• Misconnection/wrong route 3 1
• Side-effect 2 0.5
• Withdrawal 1 0.2
• Allergy 1 0.2

Kluger and Bullock. Anaesthesia 2002
57
Discharge criteria from the PACUThe Association
of Finnish Anaesthesiologists 1999

• conscious
• can secure his/her airway
• protective reflexes recovered
• ventilation and oxygen saturation adequate
• stable hemodynamics (heart rate, blood pressure)
• normothermia
• pain and PONV in adequate control
• motor block wearimg off (spinal, epidural)
• no surgical reasons requiring longer follow-up
• a plan for analgesics, antiemetics and
  intravenous fluids provided

58
Aldrete Score
59
Preoperative clinic


Operation Room OR
PACU
High Dependency Unit HD Intensive Care Unit ICU
Surgical ward
60

• PACU

PACU
SafetyComfort
Safety Comfort