The Postanesthesia Care Unit

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

11. Postanesthesia Discharge Scoring System

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: • 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)