The Post Anesthesia Care Unit

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The Post Anesthesia Care Unit
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It is not uncommon, in small country hospitals,
to have a recess or small room leading from the
operating theater in which the patients remain
until they have recovered, or at least recovered
from the immediate effects of the operation
Florence Nightingale, 1863
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The Postanesthesia Care Unit

• MOST HOSPITALS OPENED A SPECIAL AREA FOR PATIENTS
  TO RECOVER FROM THEIR ANESTHESIA IN THE 1940s
  CALLED RECOVERY ROOMS (RR)
• Primary motivation was nursing shortage

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The Postanesthesia Care Unit

• 1947 Philadelphia County Medical Society Report
• 50 of deaths which occur during the first 24
  hours after surgery were preventable by having a
  RR

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Designing the PACU

• Design should match function
• Floor space, lights, plumbing, electricity
• Location and size
• Monitoring equipment
• Emergency equipment
• Personnel

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The PACU Nurse Manager

• Diplomat - interacts with other services
• Develops staffing strategy
• Policies and procedures
• Staff development
• Performance evaluations

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Patient Care in the PACU

• Admission
• Apply oxygen and monitor
• Receive report
• Monitor and observe
• Achieve cardiovascular stability
• Achieve respiratory stability
• Achieve pain control
• Discharge from PACU

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Standards for PACU Care

• Developed by professional organizations
• ASPAN
• ASA
• AANA
• Establish minimum levels of care
• Protect both the patient the provider

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ASPAN Standards of Care

• Patient rights and ethics
• Environment
• Personnel management
• Continuous quality improvement
• Research
• Multidisciplinary collaboration

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ASPAN Standards (continued)

• Assessment
• Planning and implementation
• Evaluation
• Advanced cardiac life support
• Pain management

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ASA Standards for PACU Care

• Standard I
• All patients should receive appropriate care
• Standard II
• All patients will be accompanied to the PACU by a
  member of the anesthesia care team
• Standard III
• Upon arrival, the patient will be reevaluated and
  report given to the PACU nurse

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ASA Standards

• Standard IV
• The patient shall be continually monitored in the
  PACU
• Standard V
• A physician will be responsible for signing the
  patient out of the PACU

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Transport from the O.R.

• Do not transport until
• Patient has stable airway
• Ventilation is adequate
• Hemodynamics are stable
• Does every patient need transport oxygen?

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Things to Take

• All patient records
• All controlled drugs
• Airway equipment / oxygen
• If indicated
• suction
• pulse oximetry
• invasive monitors

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Admission to PACU

• Coordinate prior to arrival
• Administer oxygen / assess airway
• Apply monitors
• Obtain vital signs / temperature
• Assess the patient
• Receive report from anesthesia personnel

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Monitoring in the PACU

• Baseline vital signs / temperature
• Respiration
• Observation
• Pulse oximetry
• Capnography
• Circulation
• ECG
• Blood pressure / pulse
• Level of consciousness

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Pulse Oximetry

• Standard of care
• Should be first monitor applied
• Documents delivery of oxygenated blood to a
  peripheral site
• Documents presence of a pulse
• Utilizes 2 wave lengths of red light

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Capnography

• Documents carbon dioxide in exhaled air
• Indicates adequacy of ventilation
• Shows rhythmic respiratory pattern
• Provides characteristic wave forms

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Blood Pressure

• Obtain baseline readings
• Shivering may affect accuracy
• Adjust transducer to proper height

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ECG

• Help PACU personnel apply leads
• May need new ECG pads
• Note the rate and rhythm
• Note ST segment compared to intraoperative tracing

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Temperature

• Expect hypothermia
• Keep covered during transport and admission to
  the PACU
• Actively rewarm in cold

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Initial Assessment

• Color
• Respiration
• Circulation
• Consciousness
• Activity

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Color

• Pink 2 points
• Pale / dusky 1 point
• Cyanotic 0 points

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Respiration

• Can deep breathe and cough 2 points
• Shallow but adequate breath 1 point
• Apnea or obstruction 0 points

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Circulation

• BP within 20 of baseline 2 points
• BP within 20-50 of baseline 1 point
• BP deviating gt50 0 points

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Consciousness

• Awake, alert, oriented 2 points
• Arousable, but readily sleeps 1 point
• No response 0 points

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Activity

• Moves all extremities 2 points
• Moves 2 extremities 1 point
• no movement 0 points

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PACU Report

• Patients name and age
• Surgical procedure
• Type of anesthesia
• Preoperative vital signs
• Coexisting disease

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PACU Report (cont.)

• Drugs of interest
• narcotics / sedatives
• relaxants / reversal
• antibiotics (dose and time)
• vasoactive drugs
• steroids
• other non-routine drugs

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PACU Report (cont.)

• Preoperative medications
• Routine
• Sedatives administered by anesthetist
• Allergies
• Blood loss / urine output
• Fluid replacement

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PACU Report (cont.)

• Intraoperative lab results
• trends
• most recent
• Anesthetic / surgical complications
• Special treatments
• Special considerations

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Common PACU Problems

• Airway obstruction
• Arterial hypoxemia
• Hypoventilation
• Hypertension
• Cardiac dysrhythmias
• Oliguria

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Common PACU Problems (cont.)

• Bleeding
• Hypothermia
• Agitation upon emergence
• Delayed emergence
• Nausea and vomiting
• Pain

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During the PACU Stay

• Close observation
• Airway
• Vital signs / ECG
• Hemorrhage
• Fluids - in and out
• Level of consciousness
• Pain
• Nausea

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Airway Obstruction

• Most common tongue in posterior pharynx
• May be foreign body
• Inadequate relaxant reversal
• Residual anesthesia

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Airway Obstruction Treatment

• Verbal/Physical stimulation
• Oral Airway
• Nasal Airway
• Tracheal intubation
• Cricothyroidotomy
• Trachostomy

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Hypoventilation

• Residual anesthesia
• Narcotics
• Inhalation agent
• Residual Relaxant
• Post op Analgesia
• Intravenous
• Epidural

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Hypoventilation Treatment

• Stay with patient
• Assess the problem
• Reverse relaxant
• Reverse narcotic
• Reverse midazolam
• Use graded response

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Hypertension

• Common response to SNS stimulation
• Pain
• Full Bladder
• Common in hypertensive patients
• Also, consider
• Fluid overload
• IIP

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Hypertension Treatment

• Pain control
• Beta blockers
• Alpha blockers
• hydralazine (Apresoline)
• Calcium channel blockers
• Use graded response

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Hypotension

• Decreased venous return
• Most common cause
• Hypovolemia
• sympathectomy
• 3rd space loss
• Left ventricular dysfunction

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Hypotension

• Common scenario Arrive hypothermic,
  vasoconstricted, and normotensive. As patient
  rewarms, he/she vasodilates and becomes
  hypovolemic.
• Initially treat with fluid bolus

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Dysrhythmias

• Secondary to
• hypoxemia
• hypercarbia
• acidosis
• late catecholamines
• Bradycardia may allow escape beats
• Electrolyte abnormalities
• Hypothermia

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Dysrhythmia Treatment

• Identify and treat the problem
• Assure oxygenation
• Pharmacology as needed

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Urine Output

• Oliguria
• Hypovolemia
• Surgical trauma to ureters
• Impaired renal function
• Mechanical blocking of catheter
• Assess catheter patency
• Fluid bolus
• Lasix

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Urine Output

• Polyuria
• Common after surgery
• Osmotic Diuresis
• Better renal perfusion
• Consider other problems
• High output failure
• DI/DM
• Pituitary

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Post op Bleeding

• May be internal or external
• Usually surgical problem
• consider coagulopathy
• Open fluids/start lines
• Notify surgeon
• Order blood
• Prepare to return to OR

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Hypothermia

• Assume that all patients will arrive cold
• Get baseline temperature
• Actively rewarm
• Administer oxygen if shivering

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Altered Mental Status

• Range from lethargy to combativeness
• Always protect the patient
• Reaction to drugs?
• Sedatives
• Anticholinergies
• Consider baseline mental status
• Intoxication/Drug use

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Altered Mental Status (cont..)

• Pain
• Distended bladder
• Hypoventilation
• Low cardiac output
• CVA

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Treatment of Altered Mental Status

• Carefully evaluate patient
• If possible, protect patient and wait for
  anesthesia to wear off
• Careful treatment of symptoms
• Sedatives/narcotics if stable
• Verbal reassurance

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Delayed Emergence

• Systematic evaluation
• Pre-op status
• Unusual intraoperative events
• Ventilation
• Response to Stimulation
• Cardiovascular status

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Delayed Emergence (cont..)

• Residual anesthesia is most common cause
• Consider reversal
• Hypothermia (Profound)
• Diabetes
• Underlying psychiatric problem
• Neurological consult

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Postoperative Nausea Vomiting

• Leading cause of unexpected admission
• Risk factors
• Type of surgery
• Type of anesthesia
• Hormone levels
• Autonomic involvement

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Prevention of Emesis

• NPO status
• Droperidol
• Metoclopramide
• Histamine blockers
• Ondansetron
• Propofol

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Postoperative Pain

• May alter other physiologic parameters
• Based on the patients perception
• May lead to unexpected hospital admission

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PACU Pain Control

• Asses the patient to determine the cause of the
  pain.
• Pain may be related to non-surgical causes
• full bladder
• caffeine withdrawal
• Hypothermia
• Hypoxia

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Pain Control

• Narcotics
• titration to effect
• watch for respiratory depression
• early use of the PCA pump
• routes of administration
• IV / IM
• oral / rectal
• SAB / epidural

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Narcotic Agonist/Antagonist

• Nubain
• Stadol

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Spinal / Epidural Narcotics

• Provide prolonged analgesia
• Side effects
• respiratory depression (immediate. vs.. delayed)
• nausea
• pruritis
• motor block

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SAB / Epidural

• Clonidine has been shown to enhance analgesia and
  reduce side effects from epidural opioids

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Non-Narcotic Analgesics

• Ketorolac
• Clonidine

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Sedatives

• Do not relieve pain
• Reduce anxiety
• May provide amnesia

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Regional Blocks

• Interscalene
• Caudal
• Intercostal
• Local infiltration

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Other Options for Pain Control

• (TENS) Transcutaneous electric nerve stimulation
• Hypnosis
• Verbal reassurance
• Placebo

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PACU Discharge Criteria

• Awake with muscle strength
• Patent airway / good respiratory function
• Stable vital signs
• Patency of tubes, catheters, IVs
• Condition of surgical site
• Comfort / anxiety