POST ANAESTHESIA CARE

By : Dr. Nur Aiza IdrisModerator : Dr. Mohd Rozi

Outline

Post Anaesthesia Care Unit Post Operative Complication

Post Anaesthesia Care Unit

Definition Staffing Design Equipment Monitoring Admission Report

Recovery Room

Definition

Activities undertaken to safely manage the patient following a surgical procedure, including identification and immediate treatment of early complications of both anaesthesia and surgery before they develop into life-threatening consequences

(reference : Quality and safety guidelines of postanaesthesia care – European Society of anaesthesiology)

Activities included Monitoring Identification of post-op complication Treatment of complication

So this is the role of the PACU (post anest care unit). Their purpose is to improve postanaesthesia care outcomes for patients who have just had anaesthesia

Functions of PACU

1. Immediate postoperative treatment in the PACU,

2. Preoperative optimization of severely ill patients’ conditions in special situations

3. Titration and optimization of acute pain therapy

4. Buffer before intensive care unit (ICU), high dependency unit (HDU) or ward admission

5. Evaluation and determination of further treatment on ICU, HDU or ward

6. Improve or optimize patient’s condition for further treatment at ICU, HDU or ward.

Functions of PACU

These functions are supervised by the anesthesiologist and the surgeon.

PACU is run by the anesthesiologists and the surgeon who operate on the patient will be called if any complication occurs related to the surgical procedure.

Staffing Nurses specifically trained in the care of patients emerging from

anaesthesia Expert in : 1. airway management 2. advanced cardiac life support 3. problem with surgical patient e.g wound care, drainage catheters, bleeding Ratio of 1 recovery nurse for 2 patients Under medical direction of anaesthesiologist reflect coordinated effort between anaesthetist, surgeon &

consultants anaesthesiologist manage the analgesia, airways, cardiac,

pulmonary and metabolic problems surgeon manage any problem related to surgical procedures

Design

Location: should be locate near the OR. A central location that the pt. can be rush back to

surgery with easy and full access. Capacity:

Average, 1.5 -2 patients for each operating table, less if long-lasting procedures are dominant with slower patient turn over or more if short procedures or day case surgery.

Construction guidelines : minimum of 7 ft between beds and 120 sq ft per patient

Each patient space should be well lighted and large enough (12–15 m2 per bed as a minimum) to allow easy access to patients in spite of poles for equipments.

Average PACU stay is1-2hours, not more than 24 hours. Open ward design

- to facilitate observation of all patients simultaneously

Equipped with multiple electrical outlet, oxygen, air, suction at each space

Equipments and Facilities

Bedside monitoring devices

– pulse oxymeter

– ECG

– noninvasive blood pressure (BP) monitor Immediately available monitoring devices

– ECG recording,

– capnograph,

- Nerve stimulator

– means of measuring temperature. Specific additional monitoring (e.g. vascular or intracranial

pressures, cardiac output or some biochemical variables):

– may be required and should be performed on a case-by-case basis for selected patients or selected procedures.

Equipments and Facilities Central monitor station

– It controls and records all warnings and alarms of bedside monitors and provides documentation in the form of hard copies, and is therefore recommended.

Facilities needed

– defibrillator and resuscitation trolley appropriately supplied,

– difficult airway devices,

– immediate access to blood gas analysis and acute laboratory testing,

– access to mobile radiograph and ultrasound imaging and endoscopies,

– warming blankets,

– forced air-warming devices for each bed,

– sufficient air condition system providing a minimum of 15 air change rate per hour for sufficient scavenging of anaesthesia gases and other disinfectant vapours.

Airway maintenance kit: Laryngoscope with all size blades All sizes Endotracheal tubes Face masks, Airways, Ambu Bag Tracheostomy set ICD set ( Intercostal drain) Transport ventilator

Transfer of Patient (OR to PACU)

By suitably trained staff, under the supervision of an anaesthetist, Portable monitoring is recommended if alteration or deterioration

of patient’s condition may be anticipated or the distance of operating room and PACU makes it reasonable,

Steps should be taken to protect the patient during transfer mainly from:

– traumatic injury,

– hypoxia,

– hypothermia,

– accidental disconnections or removal of drains, lines, and catheters.

Properly designed transfer trolleys or beds are needed, equipped with:

– oxygen cylinders, masks, and tubing,

– infusion poles,

– equipment(s) to secure and support airway and assist ventilation;

– provision of clamps for drainage tubes,

– protective ‘sides’,

– a means to produce head-down tilt.

Transfer of Patient (OR to PACU)

Handover: on arrival to the receiving unit full and formal handover should take place from professional

to professional with a completed anaesthetic record and important details

of surgical procedure with specific verbal and written instructions for

postoperative care, drugs and fluid regimens must be written on appropriate

charts, the anaesthetist should ensure that recovery staff is taking

over the responsibility before leaving the patient. Observation and record keeping

It is important for the patient to be continuously monitored during the transfer.

Admission Report

Preoperative history Intra-operative factors:

Procedure Type of anesthesia EBL (Estimated Blood Loss) UO(Urinary Output)

Assessment and report of current status Post-operative instructions

Monitoring

All the patients transferred to the PACU should be monitored1. Respiratory functions (O2 sat, capnography)2. Cardiovascular stability (pulse, BP, ECG)3. Neuromuscular function (espc those received

neuromusc block agent)4. Mental status 5. Temperature 6. Pain 7. Nausea and vomiting8. Fluid and hydration9. Urine output10. Drainage and bleeding

Discharge

Duration minimum length of stay (usually around 30mins)

Patients receiving regional anesthesia should show signs of resolution of both sensory and motor blockade prior to discharge.

majority of patients can meet discharge criteria within

60 minutes in the PACU

patients with RA - show signs of resolution of both

sensory and motor blockade

- to avoid inadvertent injuries due to motor weakness or

sensory deficits

Standards for Post Anest Careapproved by ASA, 2009

1. All patients who have received general, regional or monitored anesthesia care shall receive appropiate postanesthesia management

2. 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 appropiate to the patient's condition.

3. 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

4. The patient's condition shall be evaluated continually in the PACU

5. A physician is responsible for the discharge of the patient from the PACU

RECOVERY ROOM COMPLICATIONS

COMPLICATIONS

Respiratory complications a. Airway obstruction b. Hypoventilation c. Hypoxemia

Circulatory complications a. Hypotension b. Hyertension

c. Arhythmias

Complications

Agitation Failure to regain consciousness Postoperative pain Nausea & vomiting Shivering & hypothermia

RESPIRATORY COMPLICATIONS

Most frequently encountered in PACU

AIRWAY OBSTRUCTION

Partial obstruction - sonorous respiration Total obstruction - cessation of airflow, absence breath

sounds, paradoxic chest movement ( chest descends as the abdomen rises ) Causes : a. Tongue falling back ( most common) b. Laryngospasm c. Glottic edema d. Secretions e. Vomitus / blood f. External pressure on the trachea (neck hematoma)

Management..

1. Tongue fall back

- Combined jaw-thrust and head- tilt maneuver pulls the tongue forward and opens the airway

- Insertion of oral or nasal airways - nasal airways better tolerable during emergence and lessen the likelihood of trauma to the teeth when patient bites down

2. Laryngospasm

characterized by high-pitched crowing noises; maybe silent with complete glottic closure Spasm of vocal cord following airway trauma, repeated instrumentation, or stimulation from secretions or blood in

the airway Management.. Jaw-thrust maneuver + positive airway pressure via tight-fitting face mask Insertion of oral or nasal airway - to ensure patent airway

till vocal cord Suction for any secretions or blood - to prevent recurrence

REFRACTORY LARYNGOSPASM - treated aggresively with a small dose of

succinylcholine (10-20mg) and temporary positive pressure ventilation with 100% oxygen

( to prevent hypoxaemia)

- Intubation ( occasionally necessary)

- Cricothyrotomy or transtracheal jet ventilation ( if intubation unsuccesful)

3. Glottic edema

an important cause of airway obstruction in infants

and young children

Management… IV dexamethasone 0.5mg/kg Aerosolized racemic epinephrine

Adults: 0.5–0.75 ml of a 2.25% solution in 2.0 ml normal saline. Pediatrics: 0.25–0.75 ml of a 2.25% solution in 2.0 ml normal saline

4. External pressure on trachea

Postoperative wound hematomas following

head and neck, thyroid surgery can quickly

compromise the airway

Mx .. open the wound immediately relieves

tracheal

compression

HYPOVENTILATION

Definition : PaCo2 greater than 45mmHg Mild, and many cases are overlooked Significant hypoventilation PaCo2 > 60mmHg arterial blood pH < 7.25

Clinical signs : excessive or prolonged somnolence airway obstruction slow respiratory rate tachypnea with shallow breathing Or, laboured breathing Mild to moderate acidosis - tachycardia, hypertension or

cardiac irritability Severe acidosis - circulatory depression

Hypoventilation ( cont.)

causes : residual depressant effect of anaesthetic agent on respiratory drive opiod –induced Excessive sedation Inadequate reversal Metabolic factors ( e.g hpokalemia or resp acidosis) Splinting due to incisional pain and diphragmatic

dysfunction following upper abdominal or thoracic surgery, abd

distension shivering, hyperthermia, or sepsis - increase CO2

production

Management..

Treat underlying cause Intubation ( marked hypoventilation, obtundation, severe

acidosis,circulatory depression) IV naloxone (0.04mg increments) or… IV doxapram (60-100mg , followed by 1-2mg/min) - does not reversed analgesia, but can cause

hypertension & tachycardia Cholinesterase inhibitor - for residual paralysis

Prevention.. - judicious opiod analgesia, epidural or intercostal nerve block for upper abdominal or thoracic procedures

HYPOXEMIA

Mild hypoxemia is common in patients recovering

from anesthesia Mild to moderate hypoxemia (PaO2 50-

60mmHg) in young healthy patients may be well

tolerated initially but.. With increasing duration or severity

there is progressive acidosis and circulatory

depression

Causes

Hypoventilation Increased right- to- left intrapulmonary shunting ( most common cause)

Diffusion hypoxia Decreased cardiac output Increased oxygen consumption (shivering)

Increased intrapulmonary shunting from a

decreased FRC relative to closing capacity is the most common cause of hypoxemia

following general anesthesia

upper abdominal & thoracic surgery - greater reduction in FRC

semi-upright position maintain FRC

management

Oxygen therapy - 30-60% oxygen - higher concentration in patients with underlying pulmonary or cardiac disease - guided by SPO2 or ABG

Intubation - pt with severe or persistent hypoxemia

Treat underlying cause

CIRCULATORY COMPLICATIONS

1. Hypotension

usually due to decreased venous return, left ventricular dysfunction,excessive

arterial vasodilatation

Causes..

Hypovolemia Hypothermia - venoconstriction Spinal or epidural anesthesia - relative

hypovolemia

Sepsis Allergic reactions Tension pneumothorax Cardiac tamponade Coronary artery or valvular heart disease

Management…

Mild hypotension during recovery from anesthesia

is common - reflects decrease in sympathetic

tone , associated with sleep or residual effect of

anesthetic agents (not require treatment)

Significant hypotension - reduction of BP 20-30%

below baseline (require treatment)

Fluids vasopressor or inotrope If pneumothorax - insert chest tube cardiac tamponade - pericardiocentesis or

thoracotomy

2. Hypertension

Postoperative hypertension is common within

the first 30 mins in PACU - noxious stimulation from incisional pain,

intubation or bladder distension Reflect sympathetic activation - neuroendocrine response to surgery Secondary to hypoxemia, hypercapnia,met

acidosis Systemic hypertension Fluid overload

Management

Mild hypertension – not require treament Marked hypertension - treat individualized Beta blocker ( labetolol, esmolol, propanolol)

Calcium channel blocker Hydralazine

Marked hypertension in patients with limited cardiac reserve requires direct intra-arterial pressure monitoring

3. Arrythmia

Residual effects from anesthetic agent, increased sympathetic nervous system activity, metabolic abnormalities, preexisting cardiac or pulmonary disease predispose to arrhytmia Bradycardia - residual effects of neostigmine or beta adrenergic blocker Tachycardia - effect of anticholinergic agent, vagolytic drug, beta agonist - pain - fever - hypovolemia - anemia

POSTOPERATIVE PAIN

• Asses the patient to determine the cause of the pain.

• Pain may be related to non-surgical causes - full bladder - caffeine withdrawal• Hypothermia• Hypoxia

Moderate to severe pain can be managed by parenteral opiods, RA or nerve blocks. Adequate analgesia must be balanced against excessive sedation Analgesic effect : peak within 4-5mins Pt fully awake - PCA IM opioid - delayed and variable onset ( 10-20min) - delayed resp depression ( up to 1 H)

SHIVERING AND HYPOTHERMIA

Shivering can occur as a result of : - intraoperative hypothermia - effects of anesthetic agents

Most important cause of hypothermia is a redistribution of heat from the body core

to the peripheral compartments

Other contributary factors are :

cold ambient temperature in OR prolonged exposure of a large wound use of unwarmed intravenous fluids high flows of unhumidified gases

Shivering

common during or after emergence from GA represents the body’s effort to increase heat production and raise body temperature associated with intense vasoconstriction part of nonspecific neurologic signs (posturing, clonus, or babinsk’i sign) related to duration of surgery and use of high

concentration of volatile anesthetic Not all patients who shiver postoperatively are

hypothermic, thus suggesting that mechanism of this event may be related to inadequate descending control of spinal reflexes after inhalation anesthesia.

Treatment

forced-air warming device warming lights heating blanket IV Meperedine 25 – 30mg intravenusly

NAUSEA AND VOMITING

Common following GA high incidence in :- opioid + nitrous

oxide - laparoscopic

surgery - strabismus surgery - young women Propofol anesthesia decreases incidence

Rx : iv Metoclopramide (0.15 mg/kg) iv Droperidol - 0.625-1.25 mg (0.05- 0.075

mg/kg in children) Iv Ondansetron 4mg (0.1 mg/kg in

children) - less likely to cause extrapyramidal

reaction IV dexamethasone 8-10mg

Agitation

Causes : Pain Hypoxemia,acidosis or hypotension Bladder distention Surgical complication(eg,occult intra-abd

haemorrhage) Marked preop anxiety and fear Adverse drug effects(large doses of

central cholinergics, ketamine)

Rx :Physostigmine ,1-3 mg I.V (0.05 mg/kg in children)-effective in treating delirium due to atropine and scopolamine

persistant agitation - sedation with intermittent I.V doses of midazolam,0.5-1 mg (0.05 mg/kg in children)

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