The Postanesthesia Care Unit

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The Postanesthesia Care Unit

• Jessica Lovich-Sapola MD

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PACU

• 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.

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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.
• 1920s and 30s several PACUs opened in the US
  and abroad.
• It was not until after WW II that the number of
  PACUs increased significantly. This was do 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.

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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 surgical
  anesthetic remains responsible for managing the
  patient in the PACU.

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PACU Location

• Should be located close to the operating suite.
• Immediate access to x-ray, blood bank, blood gas
  and clinical labs.
• Should have 1.5 PACU beds per operating room
  used.
• 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.

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PACU Equipment

• Automated BP, pulse ox, EKG, 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.

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Admission Report

• Preoperative history
• Intra-operative factors
• Procedure
• Type of anesthesia
• EBL
• UO
• Assessment and report of current status
• Post-operative instructions

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Postoperative Pain Management

• Intravenous opioids
• Ketorolac and anti-inflammatory drugs
• Midazolam for anxiety
• Epidural
• Regional analgesic blocks
• PCA and PCEA

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Discharge From the PACU

• 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.
• Postanesthesia 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.

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Aldrete Score
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Postanesthesia Discharge Scoring System
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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 patients 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. A physician is responsible for discharge of
  the patient.

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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 (Zofran/ Phenergan/ Promethazine)
• Propofol

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Respiratory Complications

• Nearly two thirds of major anesthesia-related
  incidents may be respiratory.
• Airway obstruction
• Hypoxemia
• Low inspired concentration of oxygen
• Hypoventilation
• Areas of low ventilation-to-perfusion ratios
• Increased intrapulmonary right-to-left shunt

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Respiratory Complications

• 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.

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Failure to Regain Consciousness

• Preoperative intoxication
• Residual anesthetics IV or inhaled
• Profound neuromuscular block
• Profound hypothermia
• Electrolyte abnormalities
• Thromboembolic cerebrovascular accident
• Seizure

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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, ASA, NTG, and morphine if needed
• 12 lead EKG
• History
• Consult cardiology

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Fever

• Causes
• Infections
• Drug / blood reactions
• Tissue damage
• Neoplastic disorders
• Metabolic disorders
• Thyroid storm
• Adrenal crisis
• Pheochromocytoma
• MH
• Neuroleptic malignant syndrome
• Acute porphyria

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Bibliography

• Miller Millers Anesthesia, 6th ed. (2005)
• Baresh Clinical Anesthesia, 4th ed. (2001)
• Morgan Clinical Anesthesiology, 3rd ed. (2002)