1. بسم الله الرحمن الرحيم

2. Postoperative care - Post Anesthesia Care Unit “PACU”

3. PACU Design should match function Location: Monitoring equipment
Close to the operating suite.
Access to x-ray, blood bank & clinical labs.
Monitoring equipment
Emergency equipment
Personnel

4. Admission to PACU Coordinate prior to arrival, Assess airway,
Administer oxygen,
Apply monitors,
Obtain vital signs,
Receive report from anesthesia personnel.

5. PACU - ASA Standards Standard I Standard II Standard III Standard IV
All patients should receive appropriate care
Standard II
All patients will be accompanied by one of anesthesia team
Standard III
The patient will be reevaluated & report given to the nurse
Standard IV
The patient shall be continually monitored in the PACU
Standard V
A physician will signing for the patient out of the PACU

6. Patient Care in the PACU
Admission
Apply oxygen and monitor
Receive report
Monitor & Observe & Manage
 To Achieve
Cardiovascular stability
Respiratory stability
Pain control
Discharge from PACU

7. Monitoring in the PACU Baseline vital signs. Respiration Circulation
RR/min, Rythm
Pulse oximetry
Circulation
PR/min & Blood pressure
ECG
Level of consciousness
Pain scores

8. Initial Assessment Color Respiration Circulation Consciousness
Activity

9. Aldrete Score 2 1 Score Activity Respiration Circulation
Consciousness
Oxygen Saturation 2
Moves all extremities
Breaths deeply and coughs freely.
BP + 20 mm of preanesth. level
Fully awake
Spo2 > 92%
on room air 1
Moves 2 extremities
Dyspneic, or shallow breathing
BP mm of preanesth. level
Arousable on calling
Spo2 >90%
With suppl. O2
Unable to move extremities
Apneic
BP + 50 mm of preanesth. level
Not responding
Spo2 <92%

10. Common PACU Problems Airway obstruction Hypoxemia Hypoventilation
Hypotension
Hypertension
Cardiac dysrhythmias
Hypothermia
Bleeding
Agitation
Delayed recovery
“PONV”
Pain
Oliguria

11. Airway Obstruction Most common tongue in posterior pharynx
May be foreign body
Inadequate relaxant reversal
Residual anesthesia

12. Management of Airway Obstruction
Patient’s stimulation,
Suction,
Oral Airway,
Nasal Airway,
Others:
Tracheal intubation
Cricothyroidotomy
Tracheotomy

13. Hypoventilation Residual anesthesia Post oper - Analgesia Narcotics
Inhalation agent
Residual Relaxant
Post oper - Analgesia
Intravenous
Epidural

14. Hypoventilation Treatment
Close observation,
Assess the problem,
Treatment of the cause:
Reverse relaxant
Reverse narcotic
Reverse midazolam

15. Hypertension Common causes: e.g. Hypertensive patients Fluid overload
Pain
Full Bladder
Hypertensive patients
Fluid overload
Excessive use of vasopressors

16. Hypertension Treatment
Effective pain control
Sedation
Anti-hypertensives:
Beta blockers
Alpha blockers
Hydralazine (Apresoline)
Calcium channel blockers

17. Hypotension Decreased venous return Hypovolemia, Sympathectomy,
 fluid intake
 losses
Bleeding
Sympathectomy,
3rd space loss,
Left ventricular dysfunction

18. Treatment of Hypotension
Initially treat with fluid bolus,
+ Vasopressors,
+ Correction of the cause

19. Dysrhythmias Secondary to hypoxemia hypercarbia Acidosis
Catecholamines
Electrolyte abnormalities
Hypothermia

20. Dysrhythmia Treatment
Identify and treat the cause,
Assure oxygenation,
Pharmacological

21. Urine Output Oliguria Treatment: Hypovolemia, Surgical trauma,
Impaired renal function,
Mechanical blocking of catheter.
Treatment:
Assess catheter patency
Fluid bolus
Diuretics e.g. Lasix

22. Post op Bleeding Causes: Treatment: Usually surgical problem
Coagulopathy
Treatment:
Start i.v. lines  push fluids
Blood sample,
Cross matching, CBC,
Notify the surgeon,
Correction of the cause

23. Hypothermia Most of patients will arrive cold Treatment:
Get baseline temperature
Actively rewarm
Administer oxygen if shivering
Take care for:
Pediatric,
Geriatric.

24. Altered Mental Status Reaction to drugs? Pain Full bladder
Drugs e.g. sedatives, anticholinergics
Intoxication / Drug abusers
Pain
Full bladder
Hypoventilation
Low COP
CVA

25. Treatment of Altered Mental Status
Reassurances,
Always protect the patient,
Evaluate the cause,
Treatment of symptoms,
Sedatives / Opioids if necessary.

26. Delayed Recovery Systematic evaluation Pre-op status
Intraoperative events
Ventilation
Response to Stimulation
Cardiovascular status

27. Delayed Recovery The most common cause: Hypothermia,
Residual anesthesia  Consider reversal
Hypothermia,
Metabolic e.g. diabetic coma,
Underlying psychiatric problem
CVA

28. Postoperative Nausea & Vomiting “PONV”
Risk factors
Type & duration of surgery,
Type of anesthesia,
Drugs,
Hormone levels,
Medical problems,
Autonomic involvement.

29. Prevention of PONV NPO status Droperidol, Metoclopramide, H2 blockers,
Ondansetron,
Acupuncture

30. WHO Algorithm for Management of Pain
+ Multidisciplinary:
Adjuvant therapy.
Psychotherapy.
Physioltherapy.
Causal diag. & ttt.
+ Adjuvant therapy
WHO III Strong opioids
+ Adjuvant therapy
WHO class II Weak opioids
+ Adjuvant therapy
WHO class I PNSAIDs

31. Regional Blocks Local infiltration Peripheral nerve blocks
Plexus block:
UL: Brachial PB
LL: Lumbar PB
Thoracic: Intercostal, Interpleural, Paravertebral
Epidural:
Thoracic
Lumbar
Caudal

32. PACU Discharge Criteria
Fully Awake,
Patent airway,
Good respiratory function,
Stable vital signs,
Patency of tubes, catheters, IV’s
Pain free,
Reassurance of surgical site.

33. Postanesthesia Discharge Scoring System
Vital Signs
(PR & ABP)
Activity
PONV
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

34. Post-operative Care “PACU”
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