Presentation on theme: "The Postanesthesia Care Unit"— Presentation transcript:
1 The Postanesthesia Care Unit Jessica Lovich-Sapola MD
2 PACURecovery 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 PACUMethods 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 StaffingOne 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 EquipmentAutomated 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: ProcedureType of anesthesiaEBLUOAssessment and report of current statusPost-operative instructions
8 Postoperative Pain Management Intravenous opioidsKetorolac and anti-inflammatory drugsMidazolam for anxietyEpiduralRegional analgesic blocksPCA 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 ConsciousnessOxygen Saturation2: Moves all extremities voluntarily/ on command2:Breaths deeply and coughs freely.2: BP + 20 mm of preanesthetic level2:Fully awake2: Spo2 > 92% on room air1: Moves 2 extremities1: Dyspneic, shallow or limited breathing1: BP mm of preanesthetic level1: Arousable on calling1:Supplemental O2 required to maintain Spo2 >90%0: Unable to move extremities0: Apneic0: BP + 50 mm of preanestheic level0: Not responding0: Spo2 <92% with O2 supplementation
11 Postanesthesia Discharge Scoring System Vital Signs (BP and Pulse)ActivityNausea and VomitingPainSurgical Bleeding2: Within 20% of preoperative baseline2: Steady gait, no dizziness2: Minimal: treat with PO meds2: Acceptable control per the patient; controlled with PO meds2: Minimal: no dressing changes required1: % of preoperative baseline1: Requires assistance1: Moderate: treat with IM medications1: Not acceptable to the patient; not controlled with PO medications1: Moderate: up to 2 dressing changes0: >40% of preoperative baseline0: Unable to ambulate0: Continues: repeated treatment0: Severe: more than 3 dressing changes
12 PACU Standards1. 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: HypoxiaHypotensionPainAnxietyInfectionChemotherapyGastrointestinal obstructionNarcotics/ volatile anesthetics/ etomidateMovementVagal responsePregnancyIncreased ICPDo:IV fluidsMedications (Zofran/ Phenergan/ Promethazine)Propofol
14 Respiratory Complications Nearly two thirds of major anesthesia-related incidents may be respiratory.Airway obstructionHypoxemiaLow inspired concentration of oxygenHypoventilationAreas of low ventilation-to-perfusion ratiosIncreased 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 intoxicationResidual anesthetics: IV or inhaledProfound neuromuscular blockProfound hypothermiaElectrolyte abnormalitiesThromboembolic cerebrovascular accidentSeizure
17 Myocardial Ischemia Increased risk: History of CADCHFSmokerHTNTachycardiaSevere hypoxemiaAnemiaSame risk if the patient has GA or regional anesthesia.TreatmentOxygen, ASA, NTG, and morphine if needed12 lead EKGHistoryConsult cardiology