Postanesthetic care

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Postanesthetic care
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Recovery room

• Recovery rooms have been inexistence 35-40 years
• As surgical prcedures increasing complex sicker
  patients recovery room care were extend beyond
  first few hours after surgery

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• Some critically ill patients were kept in the RR
  overnight.
• The success of the RR was a major factor in the
  evolution of modern surgical intensive care unit.
  

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• Now they refer to as post anesthetic care units
  (PACU)
• As the conclusion of most operations, anesthetics
  agent were discontinued, monitors were
  disconnected, and the pt. were taken to the PACU.

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• Pts .are routinely observed in the PACU following
  regional general anesthesia.
• Most guidelines require pt. to admit to PACU
  except by specific order of the attending
  anesthetist.

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• After brief verbal report to the PACU nurse, th
  pt. is left in the PACU until the major effect of
  anesthesia is worn off.
• This period is high incidence of potentially life
  threatening respiratory circulatory
  complications.

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Objective of the PACU

• Care monitor pts. during anesthetic wear off in
  the first few hours after surgery.
• Monitor especialy respiratory circulatory
  complications and vital organ.
• Early detect surgical complication eg. bleeding,
  drainage.
• Post op pain

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Design

• The PACU should be locate near the OR.
• A central location that the pt. can be rush back
  to surgery or need staff can quickly attend to
  the pt.
• The transfer critically ill pt. to the elevator
  or long corridors can jeopardise this care.
• A ratio of 1.5 bed PACU/OR

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Equipments

• Full monitorings ?spo2,EKG,NIBP,sphygmomanomitors,
  
• Capnograph, transducing pressure to direct
  arterrial ,CVP ,PCWP ,temperature
• Own supplies basic emergency equipments.
• Catheter for vascular canulations.
• Oxygen equipments, respiratory therapy
  equipments, ventilators

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staffing

• The PACU staff only by nurses specific trained in
  the care of patients emergence from anesthesia.
• Expertise in airways management ACLS ,commonly
  problems relate to wound care, draniage catheter,
  bleeding.
• Average PACU stay is1-2hours.

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Care of the patient,emergence from general
anesthesia

• Recovery from GARA is great of physiologic
  stress airways obstruction
• -shivering
• -agitation
• -delilium
• -pain
• -nausea/vomiting
• -autonomic lability ?loss of
  compensation reflex
• -hypothermia

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• During tarnsport to the recovery room is
  frequently airways obstruct, shivering,
  agitation, delirium,pain, nausia, vomiting,
  hypothermia, autonomic lability.
• RA-?decrease in BP, symphatolytic effects of
  regional block, loss of reflex vasoconstriction.

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• Speed of emergence in inhalation base anesthetic
  depend on alveolar ventilation, but inverse
  proportion to blood gas solubility.
• A duration of anesthesia,total tissue uptake,
  agent solubility, concentration use, nitrus oxide
  use.
• The most frequent cause of delay emergence from
  inhalation anesthesia is hypoventilation.

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• Emergence from intravenous anesthesia is depend
  on redistribution rather than elimination half
  life.
• Total drug dose accumulation effect ,advance
  age, hepatic ,renal disease can prolong
  emergence.
• Type dosage of pre medication, pre op sleep
  deprivation ,drug ingest ( alcohol, sedative)

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Delay emergence

• Pts.fail to regain conscious in 60-90 minutes
  after GA.
• The most frequent cause is residual anesthetic
  ,sedative ,analgesic drug effect.
• Antidote ?naloxone , flumacinil can exclude
  opioidbensodizepine effects.
• Physostigmine can exclude nuromuscular blockade.

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Less common cause of delay emergence

• Hypothermia esp. core templt33 c.
• Mark metabolic disturbance
• Preoperative stroke
• Hypoxia/hypercarbia
• Hyper ca, hyper mg,hypo Na,hypo-hyperglycemia

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Transport from the operating room

• Usually complicate by lack of adequate monitors,
  drugs ,resuscitive equipments.
• Pt. should not leave unless stable patent airway,
  adequate ventilation, hemodynamic stable.
• Transport with oxygen supplemment
• The positions also help either head up, head
  down, lateral position.

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Routine recovery from GA

• Vital signo2 should be checked immediately on
  arrival.
• NIBP,PR,RR routinely every 5min.for 15 min.or
  until stable ,and every 15 min. therafter,may be
  temperature.
• After check vital sign?check preop history(
  include mental status, comunication problem
  )intra op event, expected p/o problems ,post
  anesthetic order

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• All pt. recover from GA should receive 30-40 02
  to prevent hypoxia.
• Continue 02 therapy at the time to discharge base
  on sp02 reading on room air.

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Routine recovery from RA

• Pt. who heavily sedate or hemodynamic unstable
  should receive 02 supplement.
• Check sensory motor level to document
  dissipation of blockade.
• Precaution self injury from un coordinate
  extremity.
• Bladder catheterization is need for longer than 4
  hours.

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• Pain controle
• Agitation
• Nauseavomiting
• shivering

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Discharge criteria

• Esay arousable
• Full orientation
• Stability to maintainprotect airway
• Stable vital signs for at least 1 hours
• The ability to call for help if necessary
• No obvious surgical complications (such as active
  bleeding)

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Post anesthetic recovery score(PAR
score)/Aldrete score

• Colour-pink/pale or dusky/cyanotic
• Respiration-can breath deeplycough
• -shallow but adequate
• -apnea/obstruction
• Circulation-BP within 20of normal
• -20-50 normal
• -gt50 normal

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• Consiousness-awake /alert/oriented
• -arousable but readily
  drift back to sleep
• - no response
• Activity move all extremity
• -move 2 extremity
• - no movement
• failure of spial / epidural block to resolve
  after 6 hours possibility spinal cord /epidural
  hemaotoma

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• Should be discharge when total score10

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• Thank you for your attention.