2 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
3 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.
4 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.
5 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.
6 After brief verbal report to the PACU nurse, th pt 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.
7 Objective of the PACUCare &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
8 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
9 Equipments Full monitorings spo2,EKG,NIBP,sphygmomanomitors, Capnograph, transducing pressure to direct arterrial ,CVP ,PCWP ,temperatureOwn supplies basic &emergency equipments.Catheter for vascular canulations.Oxygen equipments, respiratory therapy equipments, ventilators
10 staffingThe 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.
11 Care of the patient, emergence from general anesthesia Recovery from GA&RA is great of physiologic stress –airways obstruction-shivering-agitation-delilium-pain-nausea/vomiting-autonomic lability loss of compensation reflex-hypothermia
12 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.
13 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.
14 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)
15 Delay emergencePts.fail to regain conscious in minutes after GA.The most frequent cause is residual anesthetic ,sedative ,analgesic drug effect.Antidote naloxone , flumacinil can exclude opioid&bensodizepine effects.Physostigmine can exclude nuromuscular blockade.
16 Less common cause of delay emergence Hypothermia esp. core temp<33 c.Mark metabolic disturbancePreoperative strokeHypoxia/hypercarbiaHyper ca, hyper mg,hypo Na,hypo-hyperglycemia
17 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 supplemmentThe positions also help either head –up, head –down, lateral position.
18 Routine recovery from GA Vital sign&o2 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 signcheck preop history( include mental status, comunication problem )intra op event, expected p/o problems ,post anesthetic order
19 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.
20 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.Routine recovery from RA
22 Discharge criteria Esay arousable Full orientation Stability to maintain&protect airwayStable vital signs for at least 1 hoursThe ability to call for help if necessaryNo obvious surgical complications (such as active bleeding)
23 Post anesthetic recovery score(PAR score)/Aldrete score Colour-pink/pale or dusky/cyanoticRespiration-can breath deeply&cough-shallow but adequate-apnea/obstructionCirculation-BP within 20%of normal-20-50% normal->50% normal
24 Consiousness-awake /alert/oriented -arousable but readily drift back to sleep- no responseActivity –move all extremity-move 2 extremity- no movement*failure of spial / epidural block to resolve after 6 hours possibility spinal cord /epidural hemaotoma