1. The Postanesthesia Care Unit
Jessica Lovich-Sapola MD

2. 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.

3. 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.
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 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.

4. 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.

5. 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.

6. 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.

7. Admission Report Preoperative history Intra-operative factors:
Procedure
Type of anesthesia
EBL UO
Assessment and report of current status
Post-operative instructions

8. Postoperative Pain Management
Intravenous opioids
Ketorolac and anti-inflammatory drugs
Midazolam for anxiety
Epidural
Regional analgesic blocks
PCA and PCEA

9. 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.

10. Aldrete Score Activity Respiration Circulation Oxygen Saturation
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 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

11. Postanesthesia Discharge Scoring System
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: % 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

12. 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. A physician is responsible for discharge of the patient.

13. Nausea and Vomiting Most common complication in the PACU. DDX: Do:
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

14. 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

15. 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.

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

17. 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

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

19. Bibliography Miller: Miller’s Anesthesia, 6th ed. (2005)
Baresh: Clinical Anesthesia, 4th ed. (2001)
Morgan: Clinical Anesthesiology, 3rd ed. (2002)