ConsultantPublic hospital Authority’s

Rand Memorial HospitalFreeport, Grand Bahama

Commonwealth of Bahamas

Dr. Mridul M. Panditrao

The Post- Anaesthesia Care

(PAC)

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

Must be carried out in a well planned, protocol based fashion

PAC

Definition

It is the specialized care given to the patients who have undergone anaesthetic management, by a team of well trained professionals, in a specially designed, equipped and designated area of the hospital

PAC Vs. Post operative care PAC is provided to anyone who has undergone anaesthesia anaesthesia might not be for a surgical

procedure patients undergoing ECT, Narco analysis patients under going Endoscopies

+ all the patients who have undergone

surgeries

PACU

Definition : It is the Specially designated Specially designed Specially located Specially staffed Specially equipped

Area of hospital, for a Specific purpose !

History of the PACU Methods of anesthesia have been available for more

than 160 years, the PACU has only been common for the past 50 years.

But one can trace it to “Lady of the lamp”: F. N. 1920’s and 30’s: several PACU’s opened in the US and

abroad. It was not until after WW II that the number of PACU’s

increased significantly. This was due to the shortage of nurses in the US.

In 1947 a study was released which showed that over an 11 year period, nearly half of the deaths that occurred during the first 24 hours after surgery were preventable.

1949: having a PACU was considered a standard of care.

PACU Location Should be located close to the Operating Theater Immediate access to x-ray, blood bank, blood gas and clinical

labs. An open ward is optimal for patient observation, with at least

one isolation room. Central nursing station. Piped in oxygen, air, and vacuum for suction. Requires good ventilation, because the exposure to waste

anesthetic gases may be hazardous. National Institute of Occupational Safety (NIOSH) has

established recommended exposure limits of 25 ppm for nitrous and 2 ppm for volatile anesthetics.

Design of PACU Size:

Ideal 1.5 PACU bed for every Operating Room 120 square foot per patient Minimum of 7 feet between beds

Facilities: Fowler’s cot with side rails Piped Oxygen, Vacuum and Air Multiple electrical outlets Large doors Good lighting Isolation for Immuno-compromised patients

PACU 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 ayahs.

PACU Equipment Multi-parametric monitors (Automated BP,

pulse ox, 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.

Capability for arterial and CVP monitoring. Supply of immediately available emergency

equipment, Crash cart, Defibrillator.

Routine Post-Anaesthesia Care Criteria for shifting from OR---to---PACU

Conscious, awake, responds to simple commands

Haemo dynamic stability Clinical evaluation and complete recovery

from NM blockade Maintenance of Oxygen Saturation Normothermia

PACU Standards 1. All patients who have received general anesthesia,

regional anesthesia, or monitored anesthesia care should receive postanesthesia management.

2. The patient should be transported to the PACU by a member of the anesthesia care team that is knowledgeable about the patient’s condition.

3. Upon arrival in the PACU, the patient should be re-evaluated and a verbal report should be provided to the nurse.

4. The patient shall be evaluated continually in the PACU.

5. Anaesthsiogist, concerned is responsible for discharge of the patient.

Admission Report

Preoperative history Intra-operative factors:

Procedure Type of anesthesia Estimated Blood Loss (EBL) Urine output

Assessment and report of current status Post-operative instructions

Postoperative Pain Management Intravenous opioids Diclofenac, I.V. Paracetamol and anti-

inflammatory drugs Midazolam for anxiety Epidural : LAAs and their adjuvants Regional analgesic blocks PCA and PCEA

Discharge criteria from PACU Neither an arbitrary time limit nor a discharge

score can be used to define a medically appropriate length stay in the PACU accurately

All patients must be evaluated by anesthesiologist prior to discharge from PACU

Criteria for discharge developed by the Anesthesia department

Criteria depends on where the patient is sent – ward, ICU, home

Discharge criteria from PACU 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)

Discharge From the PACU 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: 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.

Standard Aldrete Score

Activity Respiration Circulation Consciousness Oxygen Saturation

2: Moves all extremities voluntarily/ on command

2:Breaths deeply and coughs

freely.

2: BP + 20 mm of preanesthetic level

2:Fully awake 2: Spo2 > 92% on room air

1: Moves 2 extremities

1: Dyspneic, shallow or limited breathing

1: BP + 20-50 mm of preanesthetic level

1: Arousable on calling

1:Supplemental O2 required to maintain Spo2 >90%

0: Unable to move

extremities

0: Apneic 0: BP + 50 mm of preanestheic level

0: Not responding 0: Spo2 <92% with O2 supplementation

Post-anesthesia Discharge Scoring System (PADSS)

Vital Signs (BP and Pulse)

Activity Nausea and Vomiting

Pain Surgical Bleeding

2: Within 20% of preoperative baseline

2: Steady gait, no dizziness

2: Minimal: treat with PO meds

2: Acceptable control per the patient; controlled with PO meds

2: Minimal: no dressing changes required

1: 20-40% of preoperative baseline

1: Requires assistance

1: Moderate: treat with IM medications

1: Not acceptable to the patient; not controlled with PO medications

1: Moderate: up to 2 dressing changes

0: >40% of preoperative baseline

0: Unable to ambulate

0: Continues: repeated treatment

0: Severe: more than 3 dressing changes

Safe guidelines for discharging to home after ambulatory surgery Patient should be able to stand & take a few

steps ( sit on bed if C/ I for standing) Should be able to sip fluids Should be able to urinate Should be able to repeat post-operative

management Should be able to identify the escort

(cognitive function)

Post Operative Complications Nausea and Vomiting Respiratory Complications Failure to Regain Consciousness Circulatory Complications Fever

Nausea and Vomiting Most common complication in the PACU.

DDX: Hypoxia Hypotension Pain Anxiety Infection Chemotherapy Gastrointestinal obstruction Narcotics/ volatile anesthetics/ etomidate Movement Vagal response Pregnancy Increased ICP

Do: IV fluids Medications (Ondansetron/ metoclopramide/ Promethazine) position

Respiratory Complications Nearly two thirds of major anesthesia-related

incidents may be respiratory Do:

Go to see the patient! Assess the patients vital signs and respiratory

rate. Evaluate the airway. R/o obstruction or foreign

body. Mask ventilate with ambu if necessary. Intubate and secure the airway. Look for causes of hypoxia.

Send ABG, CBC, BMP. Get CXR.

Respiratory Complications

Airway obstruction Hypoxemia

Low inspired concentration of oxygen Hypoventilation Areas of low ventilation-to-perfusion ratios Increased intrapulmonary right-to-left shunt

Increased Left to Right shunt

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

Respiratory Complications Hypoxemia:

Low FIO2: Diffusion hypoxemia (N2O 31 times more soluble

than O2) Hypoventilation:

Inadequate N.M. blockade recovery Respiratory depressant effect of volatile agents,

narcotics, benzodiazepines Hypocapnia intra operatively Upper abdominal incisions

Respiratory Complications Increased Right to Left Shunt:

Atelectasis: Inadvertent endobroncial intubationAteclectasis of the lungIncreased Shunt ( R to L )Blockage of Brochus by blood or mucous plug

Pnemothorax: following rib injury following CVP placement

Failure to Regain Consciousness Preoperative intoxication Residual anesthetics: IV or inhaled Profound neuromuscular block Profound hypothermia Electrolyte abnormalities Thromboembolic cerebrovascular accident Seizure

Circulatory Complications:

Hypotension: Decreased preload Decreased myocardial contractility Increased after load

Circulatory Complications: Decreased preload:

Increased blood loss Increased III space loss Un diagnosed urinary loss Septicemia

Decreased myocardial contractility: Depressant effect of GA drugs Pre-existing ventricular dysfunction Per operative Myocardial infarction

Decreased After load: Volatile agents depression Septic shock Profound decreased SVR

Septic shock Volatile agents effects

Circulatory Complications: Hypertension:

Pain Hypercapnia Hypothermia Hypoxemia Excess Intra vascular volume Pre-existing hypertension

Circulatory Complications: Arrythmias:

Electrolyte imbalance ( K ) Hypoxia Hypercarbia Metabolic acidosis

Circulatory Complications: Myocardial Ischemia Increased risk:

History of CAD CHF Smoker HTN Tachycardia Severe hypoxemia Anemia

Same risk if the patient has GA or regional anesthesia. Treatment

Oxygen, Streptokinase, NTG and morphine if needed 12 lead EKG History Consult cardiology

Fever

Causes: Infections Drug / blood reactions Tissue damage Neoplastic disorders Metabolic disorders

Thyroid storm Adrenal crisis Pheochromocytoma MH Neuroleptic malignant syndrome Acute porphyria

Summary & Conclusion

Anaesthesia is becoming very sophisticated! PAC is an absolutely essential care given by

a team of professionals!! Anaesthesiologists and Trained nursing staff

are the most important members of PACU!!! Thorough understanding of pathophysiology

of this period is very essential!!!! With well organized PACU, one can prevent

lot of post-operative morbidity & mortality!!!!!!

THANK

YOU!