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Postanesthesia Care of Adults

COURSE PRICE: $30.00CONTACT HOURS: 4This course is available until March 1, 2012.

Wild Iris Medical Education (CBRN Provider #12300) is approved as a provider of continuing education forRNs, LVNs, and respiratory therapists by theCalifornia Board of Registered Nursing.

Wild Iris Medical Education, Inc. is accredited as a provider of continuing nursing education by theAmerican Nurses Credentialing Center's Commission on Accreditation.

Nurse practitioners may apply these contact hours to pharmacy continuing education and prescriptiveauthorization.

The planners and authors of this CE activity have disclosed no relevant financial relationships with anycommercial companies pertaining to this activity.

This course includes straightforward answers to basic questions about the PACU for nurses who advise patients over the telephone(see Part 6: Telephone Counseling).

By Mi chael Jay K atz, MD, PhD

Copyr i ght © 2008 Wi l d I r i s Medi cal Educati on, I nc. A l l Ri ghts Reserved.

LEARNING OBJECTIVESUpon completion of this course, you will be able to:

Describe the facilities and explain the staffing of a postanesthesia care unit (PACU).

Identify the steps taken during a patient's normal recovery from anesthesia.

Summarize the causes, recognition, and management of medical complications in the PACU.

Discuss the challenges in the operation of a PACU.

Surgery's many stresses—arising from anesthesia, muscle relaxants, and tissueinjury—push a patient's body to the edge of its ability to rebound naturally. Thechallenge to patients who are ill is even greater. The physiologic responses of peoplewith pre-existing problems such as heart disease, lung disease, kidney disease, ordiabetes are weaker than normal and after surgery some of these patients cannot regain

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a normal physiologic equilibrium on their own. Nonetheless, even these patients usuallyrecover successfully from surgery. A key factor in these recoveries is the highlyeffective postanesthesia care available in recovery rooms throughout the developedworld.

Today's recovery room is called a postanesthesia care unit, or PACU. The PACU isactually a short-term intensive careunit. It is staffed by specially trained nurses, and itis organized to maintain nurse-to-patient ratios of 1:1 when needed. In a PACU patientsare monitored continually so that any difficulties that develop as they emerge fromanesthesiaare quickly recognized. The PACU is largely self-sufficient: it contains a fullcomplement of the tools needed for resuscitation and for managing a wide range ofemergencies, along with a staff experienced in handling crises (Marcon, 2006).

In surgery, an anesthesiologist controls certain aspects of patients' physiology, such astheir breathing and fluid levels. When fully recovered, the patient's body re-assumescomplete control of its own life functions. During the transition from anesthesia torecovery, some patients need medical assistance to maintain a safe internal physiologicbalance. This transition also brings discomfort, such as nausea and vomiting and theawareness of pain. To manage both the potential life-threatening complications and theinevitable discomforts, specialized medical units are devoted solely to recovery fromanesthesia. The American Society of Anesthesiologists has established basic guidelinesfor PACU care. These guidelines begin by stating:

During their recovery, all anesthesia patients should be monitored in a PACU-typeunit unless the attending anesthesiologist orders otherwise. (ASA, 2004)

The PACU is the care unit to which patients are transferred directly after surgery. Later,when postoperative patients are awake, alert, and stable, either they are transferred fromthe PACU to step-down units or hospital wards, or they are discharged home. Thosepatients in critical condition are usually monitored in the PACU until the effects ofanesthesia have worn off and are then transferred to an ICU.

In some hospitals, the PACU is called a Level 1 PACU or a Phase 1 PACU, and there isa step-down unit called a Level 2 PACU or a Phase 2 PACU. (There can also be Level3 PACUs.) In this course, the PACUs that we will be examining are Level 1 PACUs.

PART 1: Postanesthesia Facilities and Staffing

THE PHYSICAL FACILITIES

Location

A PACU is a critical care unit. As in an ICU, activity is occasionally intense: manydifferent things can be going on simultaneously, and life-threatening crises can arisesuddenly. Unlike an ICU, however, a PACU has a quick turnover of patients, with theaverage patient stay being only a little more than an hour.



The fast turnover, the occasional crises, and the unpredictability of events make thelocation of the PACU important. Patients need to get from the operating room (OR) tothe PACU—and, sometimes, from the PACU back to the OR—speedily. Specialtysupport staff must be nearby; PACU nurses must be able to quickly enlist the help ofanesthesiologists, surgeons, and specialty technicians and their equipment (eg, imagingdevices).

For these reasons, the ideal location for a PACU is in the middle of the operating suite.This way, operating rooms are next door, and the OR staff of anesthesiologists,surgeons, OR nurses, and specialty technicians are in the immediate vicinity.

Layout

The typical PACU is a single open room, so staff can get to all areas quickly. This roomshould be spacious enough for easy movement of patient beds and gurneys, and itshould have large doors and good lighting. Effective ventilation is especially important;anesthetic gases exhaled by patients need to be cleared from the room, because acommonly used sedative, nitrous oxide, can be a health risk for female staff ofchildbearing age.

The floor plan of the PACU usually has the nurse and physician station and thecollective monitoring devices in an open area in the center. The bed spaces are thenarrayed individually around the perimeter of the room.

Equipment

A PACU needs its own stocks of supplies that are replenished on a regular schedule;likewise, the PACU equipment should be rechecked periodically.

Much of the patient care in a PACU involves respiratory problems. The unit needs afull complement of airway equipment, including oxygen masks and cannulas, oral andnasal airways and tubes, tracheostomy tubes, appropriate airway scopes, ventilationbags, tracheotomy trays, chest tube trays, ventilators, and aerosol treatment equipment.It also needs cardiac equipment, including a defibrillator, pacing devices and wires,electrocardiogram (ECG) equipment, an array of vascular catheters, vascular cut-downtrays, and infusion pumps. There should be an advanced life-support crash cart and acomplete stock of cardiopulmonary rescue drugs.

Patients in the PACU require intensive monitoring for short times. The number ofpatientsneeding PACU care at any one time cannot be completely predicted inadvance, so to ensure that the unit is prepared and appropriately staffed, the patient loadmust be re-evaluated continuously. To this end, the unit needs a large chart, board, orcomputer screen with frequently updated statistics, including

Number of currently available bedsStatus and anticipated discharge time of current PACU patientsAnticipated admission time of current and pending OR patients



Anticipated admission time of non-OR patients, if any

Patient Bed Spaces

The rule of thumb is that a PACU should have at least 1.5 beds for each of theoperating rooms it serves.

GENERAL BEDS

Most bed spaces in the PACU should be outfitted for general use. Around each bed,theremust be sufficient room to fit intravenous (IV) poles, pumps, a ventilator, andmobile imaging equipment. An area of ≥120 square feet should be allotted for each bedspace, and no two adjacent beds should be closer than 7 feet apart.

For each bed, there should be separate:

LightingOxygen, air, and vacuum outletsElectrical outletsSupports for IV fluids and pumpsMonitoring equipment, including:

◦ Pulseoximeter◦ Automated noninvasive blood pressure monitor◦ Oxygen flow meter

Cabinet with basic supplies, including:

◦ Gloves and masks◦ Alcohol wipes◦ Pads, sponges, drapes, and tape◦ Needles and syringes◦ Catheters, tubing, and connectors

Each bed space should have a computer or notebook for keeping a chronologic recordof all measurements and events. In addition, an ECG monitor should be available foreach bed (Freeley & Macario, 2005; Morgan et al., 2006).

CRITICAL CARE BEDS

A PACU should also have some bed spaces with additional equipment for seriously andcritically ill patients. These bed spaces need monitors that can simultaneously recordtwo or more pressures (eg, direct arterial, central venous, pulmonary artery, orintracranial). Critical care bed spaces should also be set up to control a patient's bodytemperature, with temperature monitors and with warming and cooling equipment, suchas forced-air devices or thermal blankets.



QUARANTINE BEDS

An additional walled-off and separately ventilated bed space is also useful for patientswho are either immune-compromised or infectious.

THE STAFF

The PACU is a division of the anesthesiology department, and there is always ananesthesiologist assigned to be responsible for final medical decisions in the PACU.Usually, however, a charge nurse, who also acts as a back-up care nurse when thePACU gets busy, supervises the minute-to-minute operation. In at least one hospitalwith a large PACU, an advanced practice nurse with advanced cardiac life-supportexpertise has been trained specifically to direct the PACU, under the supervision of theanesthesiology department (Frederico, 2007).

Each patient's postoperative care remains under the direction of the operatinganesthesiologist, who makes decisions related to the patient's vital functions (ie,respiration, circulation, fluid and metabolic balance) and analgesia. The operatingsurgeon is responsible for decisions about the results of the operation.

The PACU Nurse

BASIC TRAINING REQUIREMENTS

Skilled nurses provide the direct postoperative patient care in a PACU. PACU nursesshould be trained in airway management, basic life support, and the special needs ofpostoperative patients emerging from anesthesia. They should also be adept at caringfor acute surgical wounds and a variety of drainage catheters. For each PACU, ahealthcare professional trained in advanced cardiac life support should always beavailable (Morgan et al., 2006).

NURSE-TO-PATIENT RATIOS

As they begin to emerge from anesthesia, patients are more likely to have medicaldifficulties than later in their recovery; therefore, for the initial 15 minutes in thePACU, it isnecessary to have one nurse caring exclusively for that patient.

After about 15 minutes, patients who are conscious and stable can usually be monitoredby a nurse who is simultaneously watching one or even two other similar patients.Patients who are stable, conscious, and uncomplicated, and who have been in thePACU for more than a half hour, can be watched even less closely. On the other hand,patients who are unstable or who have airway complications (eg, artificial airways ormechanical ventilation) require constant close monitoring no matter how long they havebeen in the PACU (Freeley & Macario, 2005).

RECOMMENDED NURSES PER PATIENT, LEVEL I PACUs



Nurse:Patient Ratio Patient Status

2:1* Critically illUnstableComplicated problems

1:1* Newly admittedOn mechanical ventilation with an artificial airwayRequiring isolation precautionsOverflow from an ICUUnstable and requiring transfer to ICU

1:2* Both patients CSU** orOne patient CSU** and the other unconscious, but stableand uncomplicated

1:3 to 1:6* All CSU** and being considered for discharge* Wi th a second nurse avai l able. In general , the Ameri can Society ofPeriAnesthesia Nurses recommends that " two RNs, one competent i n Phase Ipostanesthesia nursing, wi l l [always] be i n the same room where the pati ent i srecei ving Phase I l evel of care" (ASPAN, 2005).* * CSU = conscious, stable, and uncompl i catedSource: K i ekkas et al ., 2005c; Torgerson, 2005; Dexter et al ., 2006.

NURSING TIME PER PATIENT

PACU nurses estimate that it takes at least 60 minutes to admit a patient, manage thepatient's recovery, get the patient ready for discharge from the PACU, and complete allthe paperwork (Freeley & Macario, 2005).

Scheduling

CONSTRAINTS

Quality care in a PACU requires that nurses monitor patients closely and, as notedearlier, PACU standards recognize that there is a limit to the number of patients thatcan be cared for simultaneously by a single nurse. Therefore, for adequate staffing, thenumber of patients in the PACU dictates the required number of nurses.

The complication in scheduling PACU nurses is that the number of postoperativepatients varies during the day. Many operations are scheduled for first thing in themorning, so PACUs often have few patients in the early morning. The peak patient loadusually comes in the middle of the day, when the morning surgeries have beencompleted. Afternoons bring fewer patients, and only emergency patients are admittedin the evening or at night.

On many days, there is a steady influx of postoperative patients, and sufficient numbersof PACU nurses must always be available. However, the intra-day variation means thatthe number of PACU nurses who are needed varies during the day. This variation ismade less predictable by prolonged surgeries and emergency surgeries.



Ideally, PACUs should schedule extra PACU nurses during all shifts throughout theday. Limited budgets, however, force the anesthesiology department to trim the numberof nurses to a minimum, and maintaining the balance between minimum staffing and anadequate safety factor is a challenge.

In addition to the fact that PACU patient admissions are unpredictable and vary duringthe day, there are other constraints that make scheduling nurses for a PACU differentfrom scheduling nurses for ICUs, operating rooms, emergency departments, hospitalwards, or clinics. These constraints include:

PACUs can only use specially trained nurses.All PACU patients will require the full attention of at least one nurse at some time intheir stay. (Although, at other times, PACU nurses can care for more than one patientsimultaneously.)PACUshave no waiting rooms, and they must minimize delays in admissions.

MAKING A DAILY ROSTER

Making daily nursing rosters for the PACU is a skill. Planning begins by including onenurse for each active operating room. When only one OR is active, a second nurse muststill be scheduled, because PACU standards require that two nurses should be in theunit at all times.

With this baseline, additional nurses are added to the schedule to match the plannedsurgeries, using the estimation that an average PACU admission occupies one nurse foran hour. Finally, the nursing roster is adjusted to match the actual patient loads thathave been seen on similar days in the past. (The past four months has been suggested asa good period to usewhen planning for the future.)

The nursing roster will always be a "best guess." As a safety factor for coping with anunexpected surfeit of patients, PACU schedulers try to assign an extra PACU nurse toless critical duties in nearby facilities, especially during peak hours. For instance, theextra PACU nurse may do preoperative preparation of patients, while being prepared toswitch to the PACU if the patient load suddenly increases (Dexter et al., 2006).

Efficient scheduling of the nursing shifts for a large PACU (ie, a PACU with >4 nurses)is complex. For a large PACU, balancing budget constraints with the necessarypostoperative patient care is too complex to be done by hand with a spreadsheetprogram; instead, it is best done by specially devised computer programs (Dexter et al.,2006; Meyer et al., 2006). Thescheduling difficulty is not always apparent at firstglance, and it can benecessary for PACU directors to take the time to explain tohospital administrators the unique problems posed by the job of efficiently staffing alarge PACU (Marcon, 2006).

PART 2: The Functioning of a PACU



Postanesthesia care is a continuation of intraoperative anesthesia management and isunder the direction of the operative anesthesiologist. Here is how the responsibilities ofanesthesiologist and PACU nurse are apportioned:

The anesthesiologist accompanies the patient during transport to the PACU.At the PACU, the anesthesiologist reassesses the status of the patient.Theanesthesiologist then reports the patient's relevant medical history and gives thepostanesthesia care orders to the PACU nurse who is assuming responsibility for thepatient's continuing care.In the PACU, nursesmonitor the patient continually, provide direct care, and notify theanesthesiologist immediately of any problems.When a patient fulfills the criteria for discharge, a PACU nurse contacts theanesthesiologist, who takes the final responsibility for discharging the patient to thenext stage of care (ASA, 2004).

THE COURSE OF A ROUTINE RECOVERY

Patients stay in the PACU until they have become awake and alert, with autonomouslystable vital signs. This recovery normally takes 30 to 70 minutes. A PACU stay isusually routine and uneventful (Sherwood et al., 2008).

During a typical recovery, a PACU nurse checks the patient frequently. Every 15minutes (or more often), the nurse records the patient's vital signs, blood oxygensaturation, level of consciousness, independence of breathing, and ability to makevoluntary movements.

When all signs have returned to pre-admission levels and have remained there for 30minutes, thenurse checks to see whether all the discharge criteria have been met.Typically, the discharge criteria include having a high score on a standardized scale,such as the Aldrete Score (introduced later). At this point, the anesthesiologist iscontacted to discharge the patient.

A routine postoperative recovery comprises four phases, each with its own protocolsand potential problems: transport to the PACU, admission to the PACU, stay in thePACU, and discharge from the PACU.

Transport to the PACU

Officially, postanesthesia care begins when a PACU nurse assumes responsibility forthe patient. However, care begins immediately after the surgery and continues duringthe transport of a patient from the OR to the PACU. During this trip, the patientrequiresspecial attention from the anesthesiologist, because patient monitors,resuscitation equipment, and emergency medications are usually not immediately athand.



GURNEYS

After ensuring that the patient has a patent airway and sufficient ventilation, the ORstaff transfers the patient to a gurney with side rails. Patients are typically transportedlying on their side to reduce the likelihood of aspiration or airway blockage fromsecretions, bleeding, or vomiting. During the journey, hypovolemic patients are oftentransported with their head lower than their feet, while patients with pulmonaryproblems may be transported with their head elevated.

CARE DURING TRANSPORT

The anesthesiologist takes direct responsibility for care of the patient during the tripfrom the OR to the PACU. Two aspects of the patient's condition need special attention:the airway and the blood oxygen level.

The transport crew ensures that the patient's airway remains clear during transport.Stable patients will often have been extubated in the operating room, and care must betaken to keep the patient's tongue forward. Unstable patients are left intubated and areaccompanied to the PACU by oxygen, ventilation equipment, vital signs monitors, anda tray of emergency medications.

Even during a short trip to the PACU, most postoperative patients become mildlyhypoxemic (ie, their blood oxygen saturation, SpO2, drops to <95%) when breathingroom air. On room air, about 10% of patients become more hypoxic and arrive at thePACU with SpO2 <90%. Older patients and overweight patients have the highest risk ofdeveloping transport hypoxemia. Due to the risk of hypoxemia, many anesthesiologistsrecommend giving most postoperative patients supplemental oxygen during transport,unless the PACU is immediately adjacent to the operating room (Morgan et al., 2006).

Admission to the PACU

THE ANESTHESIOLOGIST'S REPORT

When patients are admitted to the PACU, they should always be accompanied by theiroperative anesthesiologist. On arrival at the PACU, the anesthesiologist checks andrecords the patient's vital signs. Next, the anesthesiologist gives the PACU nurse averbal report, which is used by the PACU staff to set priorities and to individualize thepatient'scare.

PACU nurses generally know few details about patients before their arrival; therefore,the anesthesiologist's report, while brief, should be comprehensive. The report shouldgive the patient's name, age, surgical procedure, medical problems, and allergies. Adescription of the patient's preoperative mental status and any communicationdisabilities will help the PACU nurses to identify any new problems that appear duringrecovery.



Information about the surgery should include the preoperative medications, theintraoperative anesthetics and medications, an input/output record of blood, fluids, andgastric contents, and information about any intraoperative complications. The reportshould end with specific recovery orders and a telephone or pager number at which thedoctor can always be reached.

PACU ADM I TT I NG REPORT (from the operative anesthesiologist)

The PACU admitting report includes the following:

Surgical diagnosis, procedure, and outcomePreoperative

◦ Essential history and physical exam data◦ Mental status◦ Communication disabilities

Intraoperative

◦ Type of anesthesia and muscle relaxation drugs used◦ Course of surgery, any intraoperative events, any special

intraoperativemedications◦ Complications, including losses or replacements of blood or

fluids

Postoperative

◦ General care orders◦ Surgical site care◦ Medications◦ Transfusions or fluid replacements needed◦ Airway and ventilation requirements◦ Complications to watch for

There are advantages to having background medical information delivered before apatient is admitted; however, PACU nurses report that a face-to-face oral presentationby the anesthesiologist is invaluable. In a direct conversation, nurses can ask questionsimmediately, get any unclear details explained, and review the orders aloud. Moreover,PACU nurses find that they make better sense of the medical information when theycan see the patient while they are hearing the report.

An admission is a busy time. The anesthesiologist is rechecking the patient, while thePACU nurse is setting up monitors. In the midst of this activity, it is worthwhile for thenurse and the anesthesiologist to attempt a brief but uninterrupted conversation,because full concentration on the admission report makes for the most accurate andinformative handover of medical responsibilities (Curry et al., 2006).

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A RISK FACTOR PROFILE

In the admission report, the anesthesiologist warns of the possibility of certaincomplications. The receiving nurse can also screen for patients at risk for complicationsby asking whether the patient is similar to any of four basic profiles identified in thebox below.

PROFI LES OF PATI ENTS AT RI SK FOR POSTOPERATI VECOM PLI CATI ONS

Postoperative Nausea and Vomiting (PONV)

Female patientNon-smokerLong surgeryNitrous oxide during surgeryOpioids during or after surgeryHistory of PONVHistory of motion sickness

Respiratory Complications

MalepatientOlder adultLong surgeryEmergency surgeryThiopental during surgeryDiabetes or obesity

Blood Gas Problems (Hypoxemia or Hypercapnia)

Older patientThoracic or upper abdominal surgeryPre-existing lung problems or obesity

Hypothermia

Older patientLong surgeryOpen thoracic or open abdominal surgeryThyroid or adrenal deficiencyLean body



INITIAL NURSING ASSESSMENT

PACU nurses must make their own admission assessment of each patient. First, thenurse checks the patient's identity. Next, the nurse checks the patient's airway patency,vital signs, and blood oxygen saturation. Finally, these values are compared to thosereported by the anesthesiologist.

Recovery in the PACU

The American Society of Anesthesiologists (ASA) has published guidelines for PACUs(ASA, 2004). The ASA recommends that the operation of a PACU should include thesebasic policies and procedures:

All medical care in the PACU should be supervised by an anesthesiologist.An appropriately trained physician should always be immediately available forconsultation, management of complications, and cardiopulmonary resuscitation.The PACU staff should maintain full written records of all measurements and eventsduring a patient's stay.All PACU patients' breathing, blood oxygenation, circulation, and temperature shouldbe monitored continually, and each time these parameters are measured, they should berecorded using a numerical scale.In addition, a standardized recovery score should be calculated for each patient onadmission, at appropriate intervals during the PACU stay, and on discharge.

Within the bounds of these requirements, most PACUs follow similar protocols duringa typical patient's recovery from anesthesia.

ROUTINE MONITORING

After general anesthesia, most patients take 15 to 30 minutes to become fully awake, tobe breathing normally, and to be physiologically stable. Until a patient is awake andstable, vital signs and blood oxygen saturation are recorded every 5 minutes.Subsequently, blood pressure, pulse rate, and respiratory rate are measured every 15minutes. The patient's temperature is measured and recorded at least once early in thePACU stay.

Postoperative patients take time to regain effective muscular control. The ability of apatient voluntarily to maintain muscle contractions is assessed at regular intervals. Forexample, when patients are awake they should be asked to lift their head off the bed andhold it up for 5 seconds.

Depending on the patient, other physiologic parameters that might be monitoredregularly are pain, nausea, bleeding, drainage from catheters, fluid input and output,central venous pressure, and intracranial pressure. All assessments are quantified, notsimply descriptive.

OXYGEN SUPPLEMENTATION



All patients recovering from general anesthesia should receive 30% to 40% oxygenduring their emergence because temporary hypoxemia can develop, even in patientswithout major pre-existing medical problems. When patients have become alert, arebreathing smoothly on their own, and have stable signs, supplemental oxygen is usuallyno longer needed.

Even after regaining consciousness, though, a patient can become hypoxemic. Patientsshould have their blood oxygen saturation monitored until they are physiologicallystable, breathing spontaneously and sufficiently, and maintaining a normal level ofblood oxygen.

Certain patients have a greater than normal risk of developing hypoxemia and may needsupplemental oxygen during their entire stay in the PACU. Patients at higher riskinclude older adults, patients with pre-existing lung problems, and patients who havehad thoracic or upper abdominal surgery. Blood oxygen saturation should routinely bemonitored in these patients even after they are awake and alert. Patients who are proneto hypoxemia fare better when lying with their head elevated throughout their recovery(Morgan et al., 2006).

RECOVERY FROM ANESTHESIA

The PACU team's aim is for patients to emerge gradually from anesthesia. The goal isto temper any sudden changes in physiology, to minimize pain, nausea, or vomiting,and to recognize and quickly correct airway obstruction, peaks or troughs in bloodpressure, decreases in blood oxygenation, temperature changes, and delirium.

Patients come to the PACU after three classes of anesthesia, which have beenmonitored by an anesthesiologist: general anesthesia, regional anesthesia, and sedationanesthesia.

General anesthesia is also called inhalat ion anest hesia. General anesthesia usesanesthetic gases, such as fluorinated ethers (eg, desflurane, enflurane, isoflurane,sevoflurane) and nitrous oxide. These anesthetics directly affect the brain, and theyproduce unconsciousness.

Regional anesthesia uses local anest het ics (eg, bupivacaine, lidocaine, procaine) toblock nerve conduction to a part of the body. These anesthetics can be injected adjacentto the spinal cord (as spinal, epidural, or caudal blocks) or adjacent to large nervetrunks. Local anesthetics do not affect consciousness.

Sedation anesthesia uses an IV sedative-hypnotic (eg, etomidate, propofol, abarbiturate, or a tranquilizer) to produce decreased consciousness, amnesia, andlowered anxiety. When needed, a local anesthetic and an opioid can be added toprovide analgesia. Patients usually continue breathing autonomously when they areunder sedation anesthesia (Tarrac, 2006).

Intrinsic characteristics of an anesthetic can prolong the time needed for recovery.These include:



Duration of action. Each anesthetic has own characteristic rate of onset and duration ofaction. Longer-acting anesthetics require more recovery time. For example, the regionalanesthetic bupivacaine (Marcaine) remains effective longer than procaine (Novocain);therefore, patients recover more slowly from bupivacaine than from procaine.Solubility. Anesthetics that are more solublewill dissolve in body fluids at higherconcentrations, so more of the soluble anesthetic becomes sequestered in the body. Forexample, the inhaled anesthetic isoflurane is more soluble than desflurane; therefore,patients recover from isoflurane more slowly than from desflurane (Freeley & Macario,2005).

Characteristics of the patient and the surgery can also prolong the time needed forrecovery. For example:

Duration of surgery. Longer surgeries build higher concentrations of anesthetic that isstored in tissues throughout the body. Therefore, patients tend to recover more slowlyfrom long operations.Ventilation ability. Gaseous anestheticsare released from the body through the lungs.Postoperative patients with poor ventilation take longer to reduce their anesthesia load,and these patients require more recovery time.Pre-existing medical problems. Some anesthetics are broken down by the body'smetabolic processes, and some anesthetics are excreted in the urine. Patients withmetabolic or excretory problems, such as liver disease or kidney disease, tend torecover more slowly from anesthesia (Morgan et al., 2006).

COUNTERACTING MUSCLE RELAXANTS

Neuromuscular Blockade

During surgery, patients often receive nondepolarizing neuromuscular blockers (musclerelaxants). Nondepolarizing neuromuscular blockers compete with the neurotransmitteracetylcholine for receptor sites on muscle cells; this makes nerve-to-muscle signalsineffective, and the musclesbecome paralyzed. Commonly used neuromuscularblockers include mivicurium, rocuronium (Zemuron), and vecuronium.

Reversal Agents

As patients emerge from anesthesia, they need to breathe autonomously, swallownormally, cough and clear lung secretions, and sit up. To do these things, almost all theeffects of neuromuscular blockers must be gone. However, on their own, musclerelaxants wear off slowly. Therefore, after surgery, the anesthesiologist usually gives an"anti-muscle relaxant," a reversal agent. Reversal agents—anticholinesterases such asedrophonium (Enlon), neostigmine (Prostigmine), and pyridostigmine (Mestinon)—increase the signaling effect of the body's acetylcholine by slowing its normalbreakdown.

Reversal agents are effective at speeding up patients' abilities to uses their muscles.Unfortunately, the reversal agents can cause their own side effects: bradycardia,narrowing of the bronchi, contraction of intestinal muscles, and excess salivary and



bronchial secretions. These side effects are caused by stimulation of themuscarinicform of the cholinergic receptors, while the reversal effects are cause by stimulation ofthe nicot inic form of the cholinergic receptors. Therefore, the unwanted side effectscan be selectively blocked by administering muscarinic anticholinergic drugs (atropineor glycopyrrolate) along with the reversal agent (Dorian, 2005).

Monitoring Muscle Function

In the OR, anesthesiologists usually monitor the state of neuromuscular function byassessing the strength and number of muscle twitches produced by an electrical nervestimulator. In the PACU, nurses usually assess the recovery of neuromuscular strengthby the ability of patients to lift their head for 5 seconds, to squeeze the nurse's hand for5 seconds, or to stick out their tongue for 5 seconds (Barone et al., 2004).

Discharge from the PACU

The PACU nurses monitor postoperative patients for a minimum 30 minutes, but oftenthe PACU stay is longer. There is no fixed upper limit on the length of a patient's stayin a PACU: patients are watched and cared for until they can safely be transferred to aless intensively monitored unit. A typical PACU stay is approximately an hour.

As baseline requirements, the American Society of Anesthesiologists guidelines fordischarges (ASA, 2004) state:

A PACU nurse will usually make the recommendation that a patient is ready to bedischarged.A physician must be responsible for each discharge from a PACU.The patient's records should contain details of their condition at discharge.

From the PACU, patients can be discharged to a variety of settings. In some hospitals,the frontline PACU is called a Level I PACU, and there is a sequence of step-downunits (Levels II and III PACUs) offering decreasing amounts of monitoring and care.Other hospitals have a single PACU from which patients are transferred either tohospital wards, to transition areas in which they prepare to go home, or to specialty careunits, such as ICUs.

When a patient is transferred to a hospital care unit, the PACU nurse provides acomprehensive medical report to that unit. When the patient is being sent home, anadult must assume responsibility for the patient, and a PACU nurse then gives thepatient and the accompanying adult written instructions for continuing care, including atelephone number for getting answers to any questions.

DISCHARGE CRITERIA

Unless they are going to an ICU, patients who have had general anesthesia are notdischarged from the initial PACU until they:

Are awake, oriented, and able to call for help if it becomes necessary



Have clear airways, can breatheautonomously, and are maintaining a satisfactory levelof blood oxygenationHave active airway protection reflexesHave been physiologically stable with acceptable vital signs for 15–30 minutesAre not hypothermicAre not actively bleeding and have no apparent postsurgical complicationsHave controlled and tolerable levels of postoperative painAre not vomiting and have, when necessary, an anti-emesis regimen in placeHave orders and prescriptions for all required oxygen, iv fluids, and medicines(Aldrete, 1998; Smith & Hardy, 2007; Sherwood et al., 2008).

In addition, those patients who have had regional anesthesia are not discharged until thesensory and motor blocks have worn off (Kiekkas et al., 2005a; Morgan et al., 2006).

An anesthesiologist must approve each patient's discharge from a PACU.

CHECKLISTS AND SCORING SYSTEMS

Besides the clinical criteria outlined above, hospitals use standardized written criteria aspart of thedecision to discharge a patient from the PACU, and the criteria should belisted in the patient's discharge note. Standardized discharge criteria are especiallyhelpful to PACU nurses, who have the task of deciding when it is time to get ananesthesiologist's approval for a patient's discharge.

For some hospitals, the standardized criteria are a checklist of specific functionalconditions, such as those noted in the section above above. In other hospitals, thestandardized criteria are summarized in a single numerical score, which signals "allclear to discharge" when it is above a specified threshold value.

TheAldrete Scoring System (or a modified version of it) and the PostanesthesiaDischarge Scoring System (PADSS) are two numerical summary techniques that arewidely used for evaluating the level of recovery of patients after general anesthesia(Ead, 2006). Each system is formulated so that a score of 9/10 or 10/10 suggests thepatient is ready for discharge from a PACU. (See Modified Aldrete Scoring System andPostanesthesia Discharge Scoring System, below.)

The outcome of a checklist or scoring system should always be put into a clinicalcontext by the judgment of a physician. An "all clear to discharge" score should be over-ridden when a patient's pre-existing medical problems or the occurrence ofpostoperative complications make continued monitoring the prudent medical course ofaction.

MODIFIED ALDRETE SCORING SYSTEMCriterion Score

Maximum Score: 10

Source: A l drete, 1998.



Criterion ScoreMaximum Score: 10

Consciousness Fully awake 2

Aroused by verbal stimulus 1

Not aroused by verbal stimulus 0

Breathing Takes full breaths and can cough 2

Takes only shallow breathsor hasdyspnea

1

Cannot breath without assistance (apnea) 0

Blood Pressure Within 20 mm Hg of pre-op value 2

20 to 50 mm Hg different from pre-opvalue

1

≥50 mm Hg different from pre-op value 0

Oxygenation >92% blood oxygen saturation (SpO2) onroom air

2

Needs supplemental O2 to maintain SpO2>90%

1

SpO2 ≤90% on supplemental O2 0

MotorFunction

Can move all 4 extremities on request 2

Can move 2 extremities on request 1

Cannot move any extremities on request 0Source: A l drete, 1998.

Typically, a modified Aldrete score of 9 or 10 is needed to discharge a patient (Aldrete,1998). The exact Aldrete score that is used, however, can vary from hospital to hospitaland from situation to situation (e.g., Williams & Hadzic, 2005).

POSTANESTHESIA DISCHARGE SCORING SYSTEM (PADSS)Criterion Score

Maximum Score:10

Blood Pressureand Pulse Rate

Within 20% of pre-op levels 2

Between 20% and 40% of pre-op levels 1

More than 40% different from pre-oplevels

0

Ability to Walk Has steady gait and no dizziness (or pre-op level)

2



Criterion ScoreMaximum Score:

10Requires assistance 1

Unable to walk 0

Nausea andVomiting

Minimal, controllable with oral meds 2

Moderate, requires treatment with IMmeds

1

Continual despite meds 0

Pain Controlwith Oral Meds

Acceptable to patient 2

Unacceptable to patient 1

Surgical Bleeding Minimal, requiring no dressing changesin PACU

2

Moderate, requiring ≤2 dressingchanges

1

Severe, requiring >2 dressing changes 0

Typically, a PADSS of 9 or 10 is needed to discharge a patient, although the exactthreshold value can vary (Freeley & Macario, 2005; Ead, 2006).

PART 3: Medical Complications During Recovery

M edical complications during recovery include the following:

Postoperative nausea and vomiting (PONV)Postoperative painRespiratory problemsCardiovascular problemsBody temperature problemsBlood sugar level abnormalities and diabetesPostoperative agitation and deliriumDelayed emergence

The body's responses to the stress and injury of surgery include secretion of cortisol,catecholamines, cytokines, and glucagon. There is a decrease in insulin release, andthere is an increase in metabolic rate and oxygen consumption. In addition, antidiuretichormone (ADH) is released (Ali, 2005). Some of the effects of these metabolicresponses are contradictory, and together the body's responses to surgery can unbalanceimportant physiologic functions. At the same time, the lingering effects of anesthesia



and muscle relaxants weaken the body's normal ability to re-establish the physiologicbalance needed to remain healthy.

Approximately one-quarter of inpatientsand one-twelfth of outpatients havecomplications in the PACU and need individualized medical interventions (Freeley &Macario, 2005; Tarrac, 2006). The most frequent problems involve patients' upperairways. Nausea and vomiting are the next most common problems, followed bycardiovascular abnormalities, including hypotension, hypertension, and dysrhythmias(Freeley & Macario, 2005; Miller, 2006; Tarrac, 2006). In addition, surgery iscontrolled injury, so postoperative pain is an ever-present stressor that requiresattention.

A patient's admission information will give the PACU staff the first warnings ofpossible complications during recovery: the operative anesthesiologist will flag patientslikely to develop problems. The receiving nurse should also match the patient's profileagainst a checklist of some of the key risk factors for certain specific complications.(See theearlier box presenting profiles of patients at risk.)

There are a few general features that identify patients who will need close attention;these include (Freeley & Macario, 2005; Tarrac, 2006):

Poor ASA status (see ASA Physical Status Classification System, box below)General (vs. regional) anesthesiaProlonged duration of anesthesia (>2 hours)Abdominal, renal, urologic, orthopedic, or emergency surgery

ASA PHYSI CAL STATUS CLASSI FI CATI ON SYSTEM

Status and Patient Description

P1 = Normal, healthyP2 = Has mild systemic diseaseP3 = Has severe systemic diseaseP4 = Has severe systemic disease that is a constant threat to lifeP5 = Moribund, not expected to survive without surgery

Source: A SA , n.d.

POSTOPERATIVE NAUSEA AND VOMITING (PONV)

Nausea and vomiting can be experienced after all types of anesthesia, but they arecommon side effects of inhaled anesthesia. General estimates suggest that some degreeof PONV occurs in 20% to 30% of surgical cases, but various studies have reportedrates from 5% to >50% of postoperative patients, with the low rates being for patientswho had only regional anesthesia. Nausea or vomiting can hit a patient as late as 24hours after surgery (Dorian, 2005; Morgan et al., 2006).



Causes

Many factors have been associated with an increased likelihood that a patient willdevelop nausea or vomiting postoperatively. The American Society of PeriAnesthesiaNurses' evidence-based guidelines (ASPAN, 2006) suggest that, at admission, thePACU nurse should count how many basic risk factors apply to each patient. These sixbasic risk factors are:

FemalepatientNonsmokerLong surgery (>60 minutes)Opioids during or after surgeryHistory of PONVHistory of motion sickness

PACU patients with one or two of these factors have a mild risk of developing PONV,while patients with five or six factors have a high risk.

In addition to the ASPAN list of six factors, there are two other commonly cited andwell-documented risk factors related to anesthesia

Inhaled anesthesia, as opposed to regional anesthesiaSedation with nitrous oxide (Freeley & Macario, 2005)

Another predictor is the type of surgery. Certain operations are more likely to causePONV. These operations include emergency surgery when the patient's stomach is full,intraperitoneal and gynecologic surgeries, and head and neck (especially middle ear andstrabismus) surgeries.

Thepatient's condition in the PACU can also increase the likelihood of PONV. PACUpatients are at risk for nausea and vomiting when they have:

PainOpioids for painIncreased intracranial pressureHypoglycemiaDehydrationEarly administration of oral liquids (Morgan et al., 2006).

Recognition and Assessment

When PACU patients emerge from anesthesia, they should be asked whether they feelnauseated. If the answer is yes, they are asked to rate the degree of nausea on a scale of0 to 10, with 10 being the most severe. The nausea rating is then repeated after relevant



events (such as the administration of opioids for pain or antiemetics for vomiting) andat discharge from the PACU (ASPAN, 2006).

Management

The overall plan for managing PONV is:

On admission, determine the patient's risk level for developing PONV.Have patients quantify their degree of nausea (0–10) when they first awaken, duringtheir PACU stay, and on discharge.Maintain adequate hydration, blood pressure, and analgesia.Don't push oral liquids.Treat vomiting and uncomfortable levels of nausea.

The main treatments for vomiting and uncomfortable degrees of nausea aremedications, although a number of nonpharmacologic treatments can be added.

Medications

In thebrainstem, four different neurotransmitters are involved in triggering nausea orvomiting. These neurotransmitters are dopamine, acetylcholine, histamine, andserotonin. (The brainstem trigger center also contains opioid receptors.) Most of themedications used to treat nausea and vomiting are antagonists or blockers of these fourneurotransmitters (see box below). Adding a corticosteroid to the neurotransmitterantagonists can increase their effectiveness as anti-emetics.

COM M ONLY USED ANTI -EM ETI C AGENTS

Serotonin (5-HT3) Receptor Antagonists

dolasetron (Anzemet)granisetron (Kytril)ondansetron (Zofran)palonosetron (Aloxi)ramosetron

Centrally-acting Dopamine (D2) Receptor Antagonists

benzamides (domperidone [Motilium], metoclopramide)butyropenones (droperidol* , haloperidol)phenothiazines (chlorpromazine, fluphenazine, perphenazine,prochlorperazine)

Muscarinic Receptor Antagonists(Anticholinergics)



scopolamine

Histamine (H1) Receptor Antagonists

dimenhydrinatediphenhydraminehydroxyzinepromethazine

Corticosteroids

betamethasonedexamethasone

When adding a second antiemetic drug, choose one from a differenttransmitter class.

* Droperi dol i s an ef f ect i ve drug f or treati ng and preventi ng PONV, but a 2001 FDA" bl ack box" warni ng requi res ECG moni tor i ng before, duri ng, and af ter droperi dol i sused.Source: Sherwood et al ., 2008.

NONPHARMACOLOGIC TREATMENT METHODS

Acupuncture and acupressure (eg, SeaBand, ReliefBand) have been found to prevent orreduce PONV in some adults. These techniques have been used alone or in combinationwith a medication, such as a serotonin antagonist (Ghods et al., 2005; Morgan et al.,2006). In addition, the deep regular breathing used during aromatherapy has beenshown to reduce nausea (Spencer, 2004).

POSTOPERATIVE PAIN

Patients consider nausea, vomiting, and pain as the worst postoperative experiences(Freeley & Macario, 2005). There is no justification for hesitating to treat pain."Postoperative pain serves no useful purpose," writes Doherty (2006), "and may causealterations in pulmonary, circulatory, gastrointestinal, and skeletal muscle function thatset the stage for postoperative complications."

Pain after thoracic or upper abdominal surgery is the most important factor responsiblefor impaired ventilation, ineffective cough reflexes, and decreased ability to sigh andbreathe deeply, all of which can lead to atelectasis, hypoxemia, infection, andrespiratory failure (Ali, 2005).

Pain is psychologically and emotionally upsetting, and it alters a patient's physiology.Pain heightens the sympathetic tone of the body; therefore, oxygen use increases, bloodlevels of glucose are raised, proteins are catabolized, and the kidneys retain sodium and



water. Furthermore, the stress response to pain and the inflammatory response tosurgical tissue damage (eg, the local production of cytokines, prostaglandins, andleukotrienes) put the circulatory system into a prothrombotic (hypercoagulable) stateand makeblood clots more likely (Wu, 2005).

Pain is detrimental to recovery. Nonetheless, many patients still experience postsurgicalpain, because, despite the best efforts of the PACU staff, pain can be difficult toalleviate.

Causes

As a rule, the type of anesthesia does not predict the amount of postoperative pain. Onthe other hand, certain operations are associated with a higher degree of pain. Forexample, in comparisons of severity after surgery, thoracotomy leads to the most severepain, upper abdominal surgery tends to produce less severe pain, while lowerabdominal surgery seems to produce the least postoperative pain of the three.

There is also a strong psychological component to how much postoperative pain apatient experiences. Studies have documented that patients require less narcotic painrelief when they have had "a careful preoperative explanation about postoperative pain,including its character, intensity, and management, and [the explanation thatpostoperative pain is] a normal occurrence" (Freeley & Macario, 2005).


In the PACU, pain should be monitored frequently, as if it were a vital sign (ASPAN,2003c). "TheAmerican Pain Society has advocated the assessment of pain as the fifthvital sign, along with temperature, pulse, blood pressure, and respiratory rate. The fourvital signs provide a quick snapshot of a patient's general condition, but painmanagement advocates claim the picture is not complete without including pain as thefifth vital sign" (Dorian, 2005).

Even in patients who are not fully awake, pain can be recognized objectively by thephysical signs it arouses. Acute pain initiates a stress response: blood pressure and heartrate increase, pupils enlarge, cortisol levels rise, and, in the painful region, musclesoften contract spontaneously.

Of course, pain is also a subjective experience. Patients who are awake should be askedwhether they are having any pain, and, if so, where the pain is located. The patientshould also be asked to rate the pain on a 0–10 scale, with 10 denoting the most severepain. (See theVisual Analog Scale, below.) In a conscious patient, strong pain willevokeemotions: anxiety, fear, sadness, and the urge to escape.



Visual Analog Scale (VAS) for rating pain severity.

Patients are asked to mark the severity of their pain on a plain 100-mm horizontal linelabeled "no pain" at the left end and "worst pain imaginable" at the right. The VAS painscore is the distance of the patient's mark from the left end. This score is reproducibleand correlates well with other accepted pain measurement techniques.

Management

Pain treatment relieves suffering and may improve the outcome of major surgeries(Dorian, 2005). As a rule, postoperative pain is reduced most effectively when morethan one type of treatment is used concurrently. The multimodal approach includespreparing the patient beforehand, strong and complete blockade of pain during surgery,and the continuation of analgesia postoperatively (Wu, 2005).

Plans for PACU pain relief should be tailored to the specific patient, because patientsdiffer in their response to treatments. Medication is the frontline mode of pain relief,and the two general classes of pharmacologic analgesia aresystemic, such asintravenous opioids, and regional , such as local anesthetics and epidural opioids.

Medications

Opioids (narcotics) are themost powerful analgesics available, and their intravenousadministration gives pain relief in minutes. The side effects of opioids include nausea,vomiting, and sedation. The most serious problem caused by opioids is respiratorydepression, ie, a reduction in the rate and the volume of the patient's spontaneousbreathing. Antinarcotic drugs, such asnaloxone, can reverse the side effects of mostopioids.

Commonly used opioids include fentanyl, hydromorphone, meperidine, and morphine.Opioids can be given orally, parenterally, or intraspinally (intrathecally or in theepidural space), as well as subcutaneously, transcutaneously, and transmucosally.

People vary in their response to opioids; therefore, the quantity of opioid administeredshould be titrated to the most effective dose for each individual. One titrating systemfor awake and alert patients is patient-controlled analgesia (PCA), a pump and



monitor that allows patients to get a controlled dose of opioid when they feel it isneeded.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDS) block the synthesis ofprostaglandins, which are pain-enhancing molecules that are produced by the body'sinflammatory response to surgery. NSAIDs cause analgesia by a different route thanopioids, and by adding a NSAID to an opioid, pain relief is made more effective atlower doses of both medicines.

The most serious side effect of NSAIDs is bleeding from the gastrointestinal tract.Usually, this problem occurs only with long-term use. However, people over the age of75 years bleed from NSAIDs more easily. Commonly used NSAIDS includeacetaminophen, aspirin, ibuprofen, and ketorolac.

ORAL AND INTRAVENOUS DRUGS

A variety of systemic analgesic drug regimens is in common use:

For mild to moderate postoperative pain, combinations of acetaminophen and anopioid (codeine, hydrocodone, or oxycodone) are often used. Sometimes, opioid agonist-antagonists (eg, butorphanol, nalbuphine) or ketorolac are given (Morgan et al., 2006).For moderate to severe postoperative pain, opioids are the basis of treatment. Theclassic protocol for surgical pain is to begin with a small (1–3 mg) intravenous bolus ofmorphine at the end of the operation. In the PACU, for patients who are awake,morphine is then given intravenously in small boluses. The analgesic effect of eachdose peaks in 4–5 minutes; this is usually fast enough for awake patients to endure thepain while the total morphine load is safely ramped up to effective levels withoutovershooting the minimum necessary level.

Aubrun (2005) discusses titrating morphine in the PACU: A typical titrating regimenbegins when patients rate their pain intensity as ≥30 mm on a VAS line (See VisualAnalog Scale, above.) At this point, a 1–3 mg intravenous bolus of morphine is givenevery 5 minutes until the patients rate their pain <30 mm on the VAS line. The patient'sbreathing is monitored continuously, and no further morphine is given if:

The patient falls asleepRespirations drop below 12 breaths/minuteOxygen saturation drops below 95%Another serious complication arises (Aubrun, 2005)

The most serious side effect of morphine and other opioids is respiratory depression,which threatens a postoperative patient with hypoventilation. Unlike its quick analgesiceffect, morphine's effect on the respiratory drive does not peak for 20 to 30 minutes.Therefore, for at least a half-hour after morphine has been administered, PACU nursesmust continue to monitor patients and encourage them to breathe deeply and to coughoccasionally.



EPIDURAL DRUGS

Increasingly, anesthesiologists are controlling postoperative pain with epiduralinfusions or injections. Opioids are generally used, because, when administered into thespinal epidural space, opioids give fast, effective, and long-lasting pain relief. Often,the opioid is paired with a local anesthetic. Properly placed epidural analgesia willallow patients to retain control over most muscles and bodily functions.

Thecontinuous epidural infusion of an opioid requires an expertly placed and carefullycared-for catheter. The alternative to an infusion is a single injection; one epiduralinjection of slow-release morphine can provide up to 48 hours of analgesia (Keck et al.,2007).

As always with opioids, the most serious side effect is respiratory depression, andpatients' respiration must be monitored regularly; naloxone and other narcoticantagonists can reverse opioid-induced respiratory depression. Other side effects ofepidural opioidsare pruritus, nausea, vomiting, hypotension, and urinary retention.There is also some evidence of another side effect: concurrently given anticoagulantsappear to increase the risk of a spinal hematoma when epidural catheters are removed(Wu, 2005; Miller, 2006).

Improving Pharmacologic Pain Management

As many as 86% of surgical patients report having had postoperative pain that wasmoderate, severe, or extreme (Keck et al., 2007). These insufficient levels of analgesiacause emotional distress, depression, and sleep disturbance. Pain makes it difficult for aperson to breathe optimally, and pain delays movement and mobility. The stressresponse to pain also makes cardiovascular complications more likely (Aubrun, 2005).

Here are anesthesiologists' suggestions for some ways to improve postoperativeanalgesia (Freeley & Macario, 2005):

Problem: Patients in pain refuse opioids for fear of becoming addicted.Solution: Explain that narcotics given in the hospital for postoperative pain rarely leadto addiction.Problem: Patients in pain wait for PACU nurses to offer analgesia.Solution: Quiz patients frequently about pain levels, and encourage patients to acceptrelief of pain that is moderate or worse.Problem: Some patients ask for more than the usual amount of an opioid.Solution: Peoplevary widely in how much opioid is needed to produce adequateanalgesia. Consider IV patient-controlled analgesia (PCA), which tends to be animprovement over more traditional, PRN regimens. (PCA patients will need the sameregular monitoring as PRN patients.)Problem: Physicians' pain orders are too general.Solution: Formulate written protocols for various pain relief regimens. Each protocolshould have a drug name, dosage, criteria for administration, administration interval,



signs for stopping administration, and signs for calling for help. All physicians shouldbe asked to choose which specific pain relief protocol is appropriate for a patient andthen to add or change details of the protocol as needed. Nurses should not hesitate topage the physician when any questionsarise.

NONPHARMACOLOGIC METHODS

Transcutaneouselectrical nerve stimulation (TENS) and acupuncture have beenused successfully as an adjunct to analgesic medications. These and other specialtechniques are often introduced by members of pain management teams available insome hospitals.

The PACU nursing staff can also institute a number of easy and practical pain-lesseningpractices. Simply having a calm PACU staff who acknowledge a patient's discomfortwill ease patients' anxiety and diminish the impact of postoperative pain. Nurses canalso teach patients simple relaxation and breathing techniques that have been shown toreduce the severity of pain (ASPAN, 2003c).

Sometimes repositioning a patient, adding a pillow, or keeping the patient warm willtake the edge off the patient's pain. Normalizing a patient's sensory environment canalso help: giving patients their glasses, hearing aids, or dentures often eases the feelingof pain. In addition, it is helpful to keep the PACU noise level low. Finally, whenappropriate, a family member, a friend, or a religious counselor can be a soothingpresence (ASPAN, 2003c).

RESPIRATORY PROBLEMS

Most medical complications that arise during a patient's postoperative recovery involvethe patient's breathing, and the results of these breathing problems are blood gasabnormalities, namely, hypoxemia and hypercapnia.

The most common breathing problem is some degree of airway obstruction. Anotherrelatively common problem is weakened ventilation, ie, a diminished ability to takebreaths that are of sufficient depth and frequency. Typical causes of poor ventilationinclude the lingering effects of anesthesia, incomplete reversal of muscle relaxants,weakness of thediaphragm, or pain that is exacerbated by the movements of breathing.

In addition, some patients come to the PACU needing mechanical ventilation, whichposes special care requirements that are otherwise usually dealt with in an ICU.

When a patient is admitted to the PACU, the anesthesiologist should warn the receivingnurse about existing or potential respiratory problems. For example, anesthesiologistswill undoubtedly flag patients with obstructive sleep apnea. These people are likely todevelop airway obstruction when sedated, and, as a preventive measure, patients withobstructive sleep apnea are often put on nasal continuous positive airway pressure(nasal CPAP) after they have been extubated (Freeley &3038; Macario, 2005).



PACU nurses can also use simple checklists to identify patients who are at special riskfor developing postoperative breathing problems. For instance, patients with profilessimilar to the following are at higher risk for respiratory complications:

Male patientElderly (>60 years) patientLong surgery (>4 hours)Emergency surgeryThiopental during surgeryDiabetes or obesity

Upper Airway Obstruction

CAUSES

Patients can arrive in the PACU with or without an endotracheal tube. The commoncauses of airway obstruction differ somewhat in the two situations.

Patients with No Endotracheal Tube

When a patient without an endotracheal tube is sedated, airway obstruction can becaused by the tongue flopping back into the oropharynx. In patients given musclerelaxants, the oropharyneal muscles become loose and toneless and folds of wall tissuecan also contribute to the obstruction.

Laryngospasm (spasm of the vocal cords) is another cause of obstruction in extubatedpatients. (See box below.) In a similar fashion, vocal cord paralysis and edema of theglottis can also block the upper airway.

RI SK FACTORS FOR LARYNGOSPASM I N THE PACU

History of smokingChronic obstructive pulmonary disease (COPD)Difficult intubation during surgeryHistory of vocal cord surgery

Sometimes obstruction is caused by external compression of the patient's airways. Onthe outside of the neck, bandages, cervical collars, or orthopedic devices may beexcessively constrictive. Within the neck, hematomas or other swellings can push onthe oropharynx, making it bulge inward and become narrow.

Debris is another potential source of blockage. Anesthesia and sedation compromise apatient's protective reflexes, and blood, vomitus, mucus, or secretions can collect in thepatient's airways during and after surgery. Surgical patients lying on their backs can



aspirate gastric contents refluxed from the stomach, which results in gastric acidcausing bronchial constriction or food clogging the airways.

Intubated Patients

Endotracheal tubes protect airways from many types of constriction, but theendotracheal tube itself can become narrowed if a patient's teeth clamp down on it.Endotracheal tubes can also become obstructed by blood, vomitus, secretions, or debris.

During the transport of a patient from the OR, or as the patient is being settled into thePACU, the tracheal end of an endotracheal tube can be dislodged. Sometimes the tubeis inadvertently pulled back into the pharynx, and at other times the tube gets pushedinto one of the main bronchi (Barone et al., 2004).

RECOGNITION AND ASSESSMENT

Signs of airway obstruction can usually be read directly from the patient. Obstructedpatients become agitated, their nostrils flare, and they exhibit abnormal chest and neckmovements, such as sternal retractions and the use of accessory respiratory muscles asthey attempt to pull in air.

Listening to the patient can indicate the degree of blockage. Partial airway obstructioncauses noisy breathing sounds, such as snoring, stridor, or "crowing," while completeobstruction stops breath sounds altogether. When an airway is completely obstructed,carbon dioxide accumulatesquickly, leading to headaches, confusion, and thenlethargy.

In thecontext of the continuous monitoring that should be ongoing for all PACUpatients, blood oxygen saturation levels will warn of airway problems. Obstructionresults in a decreasing blood oxygen saturation (SpO2), and obstruction is one of thefirst causes PACU nurses should look for whenever oximetry values begin to decline(Barone et al., 2004; Sherwood et al., 2008).

MANAGEMENT

Patients with No Endotracheal Tube

The first step in treating apparent airway obstruction is to administer oxygen via a facemask and to ask the patient to take deep breaths. Simultaneously, the nurse should:

Look for anything external that could be compressing or constricting the patient's neckLook in the patient's mouth and oropharynx for visible blockages

If these preliminary maneuvers do not work, the nurse should physically attempt towiden the oropharynx by tilting the patient's head backward and pulling the patient'sjaw forward (head-tilt chin-lift), all the while continuing to administer oxygen.



When a head-tilt and chin-lift does not quickly ease the obstruction, a nasopharyngealor an oropharyngeal airway should be inserted. Nasopharyngeal airways cause lessgagging and vomiting in patients who are awake or semi-conscious, so oropharyngealairways are usually recommended only for heavily sedated patients. Suctioning throughthese airways can sometimes help unclog the passageway.

If airway obstruction persists, the anesthesiologist should be paged, because the nexttreatment options include insertion of an endotracheal tube and the administration ofmedications to counteract possible physiologic causes of obstruction. If laryngospasmis found, 100% oxygen should beadministered via a facemask using continuouspositive airway pressure (CPAP) ventilation (Barone et al., 2004; Freeley & Macario,2005).

Intubated Patients

As soon as intubated patients are admitted to a PACU, the placement and patency oftheir endotracheal tube is assessed. If there are uncertainties, chest films are taken andimmediately interpreted by a radiologist. After ensuring that the endotracheal tube isworking properly, the PACU nurse monitors the patient's breath sounds and oxygensaturation levels regularly (Barone et al., 2004).

Signs of obstruction are treated with oxygen and suctioning. The anesthesiologistshould be paged if the patient does not quickly improve.

Hypoxemia and Hypercapnia

Hypoxemia is an abnormally low concentration of oxygen in the blood (PaO2 <60 mmHg). Hypercapnia is an abnormally high concentration of carbon dioxide in the blood(PaCO2 >45 mm Hg).

To diagnosehypoxemia formally, arterial blood gases must be drawn and processed.Pulseoximetry is not as useful an indicator of hypoxemia; a decreased bloodoxygenation value (SpO2 <89%) usually indicates hypoxemia, but patients with higherSpO2 values can also be hypoxemic. Hypercapnia can only be measured from arterialblood gases.

CAUSES

Here are some factors that make postsurgical blood gas abnormalities more likely:

Older adult patientThoracic or upper abdominal surgeryPre-existing lung problems or obesityPulmonary edema

In the PACU, hypoxemia can be caused by insufficient ventilation, right-to-leftshunting (significant amounts of circulating blood bypassing effective lung tissue),



ventilation-perfusion mismatching (blood going to poorly ventilated lung tissue), ordiffusion impairment (eg, pulmonary edema).

Hypercapnia in the PACU is caused by insufficient ventilation of the alveoli of thelungs (Stapczynski, 2004).

The stresses of surgery can lead to any of these problems:

Pain. Pain from surgery of the thorax or upper abdomen limits a patient's ability to takefull breaths, to sigh, and to cough. These limitations can cause hypoxemia andhypercapnia.Diaphragmatic strain. Surgery in which there is traction on or injury to the diaphragmcauses the diaphragm to function poorly postoperatively. For this reason, many upperabdominal surgeries, such as open (ie, nonlaparoscopic) cholecystectomy, result in adramatic drop in patients' vital capacity during the first 24 hours. These surgeries leadto some degreeof hypoxemia in most patients. However, in patients who have littlereserve lung capacity because of pre-existing lung problems, the surgically induceddrop in vital capacity can cause respiratory failure (Ali, 2005).Airway obstruction. Airway obstruction causeshypoventilation and hypercapnia.Lower airway obstruction can be the result of bronchospasm, mucus plugs, blood,secretions, or debris. Upper airway obstruction, as discussed above, can be caused byblood vomitus, debris, secretions, or airway constriction.Lingering effects of anesthesia. The upper airways are normally cleared by coughing,but thecough reflex is weakened by anesthetics and by opioid analgesics. The lowerairways are normally cleared by the ciliary movement of particles and mucus, butciliary movement is by anesthetics, allowing obstructive mucus plugs to form afteranesthesia (Ali, 2005). The lingering effects of anesthetics will also dampen a patient'snormal respiratory drive.Incompletely reversed muscular relaxants. The persistence of neuromuscularblockadeweakens respiratory muscles, leading to less forceful, shallow breathing(hypoventilation).Pulmonary edema. Pulmonary edema and increased secretions create a barrier to gasexchange and can lead to hypoxemia and hypercapnia.Mechanical constraints. Physical limitations can cause hypoventilation. For example,obesity, bloating, tight dressings, body casts, and other restrictive apparatus will hinderbreathing. A pneumothorax will also limit a patient's ventilation capacity.The heart. For blood gas abnormalities, the underlying problem is not always in therespiratory system, especially in the case of hypoxemia. A reduced cardiac output canbe the primary cause of a decrease in a patient's blood oxygen levels after surgery.

Pulmonary Edema in thePACU

Occasionally, postoperative pulmonary edema is caused iatrogenically.Here is one possible scenario: The PACU staff are wary of hypovolemia,because it can lead to serious hypotension. A scanty urine output can



indicate hypovolemia, so a cautious PACU nurse might answer adecrease in urine output with a protective increase in intravenous fluids.

Surgery often causes fluid losses. At the same time, the body's stressresponse to surgery includes secretion of both antidiuretic hormone(ADH) and aldosterone. These hormones force the kidneys to conservewater, even when the patient is normovolemic or, worse yet,hypervolemic.

ADH and aldosterone will decrease urine output, but this can mislead acaregiver into assuming that the patient is hypovolemic. If the patient isactually normovolemic or hypervolemic, an increase in intravenous fluidscan overwhelm the circulatory system and cause pulmonary edema.(Pulmonary edema can be recognized by dyspnea, tachypnea, jugularvenousdistension, and pulmonary crackles; often there is alsotachycardia, hypertension, and an S3 gallop in the heart sounds.)

The lesson is that urine output alone is not a reliable measure of theoverall fluid load of postoperative patients. Distinguishing betweenhypovolemia, normovolemia, and hypervolemia can be difficult. Besidesurine output, caregivers must use other physical indicators of the state ofhydration, ie, vital signs, jugular venous levels, pulse pressure, cardiacfunctioning, and, when necessary, direct measurements of central venousblood pressure (Ali, 2005).


Hypoxemia

Hypoxemia is a low blood oxygen concentration, specifically, PaO2 <60 mm Hg. Anaccurate blood oxygen concentration (the partial pressure of oxygen) is obtained bymeasuring the blood gases in an arterial sample. Determining blood oxygen saturationusing a pulse oximeter is a much easier and quicker oxygen measurement, but it doesnot always correlate directly with the blood oxygen concentration. Nonetheless, SpO2

<89–90% is usually considered an indication of hypoxemia.

The values 60 mm Hg and <89—90%stated above are arbitrarily chosen thresholds,and patients can be clinically hypoxemic at higher values. Clinical signs of hypoxemiaare restlessness, tachycardia, and cardiac irritability (ie, a tendency to developirregularities in rate and rhythm). Prolonged or significant hypoxemia will lead tobradycardia, hypotension, and cardiac arrest.

Hypercapnia

Hypercapnia is carbon dioxide retention that elevates the concentration of carbondioxide in the blood to PaCO2 >45mm Hg. There is no easy way to measure the blood



concentration of carbon dioxide at the bedside; arterial blood gas measurements areneeded. Clinically, mild hypercapnia may produce no visible symptoms; for example, apatient can have hypercapnia without being cyanotic. As hypercapnia increases,however, it will lead to hypoxemia and its attendant symptoms. Continuous andprogressivehypercapnia will also cause headaches, confusion, lethargy, andsomnolence.

Respiratory Depression and Respiratory MuscleWeakness

Residual effects of anesthetics or muscle relaxants or the effects of opioids can causerespiratory depression and respiratory muscle weakness. In turn, these breathinglimitations can lead to hypoxemia and hypercapnia.

In the PACU, the degree of a patient's respiratory sedation can be monitored by notinghow well the patient breathes spontaneously and how vigorously the patient responds tothe request "Take a deep breath." The degree of residual neuromuscular weakness canbe assessed by how well patients hold their head up from the bed for 5 seconds.

MANAGEMENT

The first step in treating hypoxemia and hypercapnia is to administer oxygen. Next,while continuing oxygen treatment, the PACU nurse should search for and treat thecause of the blood gas abnormality (Sherwood et al., 2008).

Airway obstruction is frequently the culprit; its detection and management arediscussed above. Two other problems that often cause blood gas abnormalities arehypoventilation and atelectasis.

Hypoventilation

When a PACU patient suffers from hypoventilation (ie, poor movement of air into andout of alveoli) it may be a side effect of opioids. If opioid-induced hypoventilation isthe cause of blood gas abnormalities, the respiratory depression can be reversed bysmall repeated doses of a narcotic antagonist such as naloxone.

Postoperative hypoventilation can also be the consequence of intraoperative musclerelaxants that have not been fully reversed. This can occur when muscle relaxantreversal agents have been administered but have failed to act quickly or completely.Reversal agent failures can be due to hypothermia, renal failure, or hypermagnesemiain the patient. Reversal agents can also fail because of interactions with other drugs,such as gentamicin, neomycin, clindamycin, or furosemide.

Atelectasis

Atelectasis, the incomplete expansion or the collapse of regions of the lung, will causehypoventilation. Postoperative atelectasis is typically the result of lower airwayobstruction, and its treatment includes humidifying the patient's inspired air,encouraging the patient to breathe deeply and to cough, and postural drainage.



Other Conditions

When these and other initial treatments are not sufficient to reverse blood gasabnormalities, an anesthesiologist must decide whether an external CPAP mask,intubation, or other measures are needed to sustain the patient while the search for theunderlying problem continues.

CARDIOVASCULAR PROBLEMS

After respiratory problems, cardiovascular problems are the most commoncomplications seen during postsurgical recovery. Typically, cardiovascularcomplications are either the result of the surgery itself or an exacerbation of thepatient's pre-existing cardiovascular problems. This is in contrast to respiratorycomplications, which are typically the direct result medications (anesthesia, opioids,muscle relaxants).

The postoperative cardiovascular complications most commonly seen in the PACU arehypertension, hypotension, and tachycardia. Heart problems seen less often includedysrhythmias, exacerbations of heart failure, and acute myocardial infarctions.

Hypertension

Hypertension is the most common of the postoperative cardiovascular complications.When the hypertension is severe, it can cause serious problems, such as left ventricularfailure, myocardial infarction, dysrhythmias, pulmonary edema, or cerebralhemorrhage. Postoperative hypertension occurs most frequently in patients who had pre-existing hypertension (Freeley & Macario, 2005).

CAUSES

Discomfort (eg, pain, anxiety, confusion, a full bladder) can raise a postoperativepatient's blood pressure. Many physiologic abnormalities, such as hypoxemia,hypercapnia, or fluid overload, can also induce hypertension.

Certain surgeries have a higher risk of inducing a hypertensive response, notably:

Abdominal aneurysm repairCarotid endarterectomyIntracranial surgery

The strongest risk factor for postoperative hypertension is a physiologic predisposition:patients' preoperative medical conditions determine their susceptibility to developinghypertension. People with atherosclerosis or pre-existing hypertension, even if it hadbeen well controlled, are the most likely patients to develop postoperative hypertension(Tarrac, 2006).




Blood pressure is oneof the key signs that should be continually monitored in thePACU. Postoperativehypertension tends to occur early in a patient's recovery, so bloodpressuresshould be measured more frequently in the first 30 minutes of a patient's stayin the PACU.

MANAGEMENT

The goal in managing postoperative hypertension is to relieve the stressor. Whenhypertension occurs, nurses should be certain that they are providing sufficientanalgesia and that the patient's bladder is not distended. Nurses should also check and,if necessary, improve the patient's ventilation, oxygen saturation, and fluid balance.Sometimes, relieving discomfort with additional sedation can lower postoperativehypertension (Barone et al., 2004; Sherwood et al., 2008).

If thesemeasures do not reduce the patient's blood pressure, then antihypertensivedrugs are probably needed. In the PACU, beta-adrenergic blockers are commonly usedto reduce blood pressure. Labetalol and esmolol both work in a few minutes; labetalolis given in intravenous boluses, while esmolol, which has a shorter half-life, is given asa continuous infusion (Freeley & Macario, 2005).

Hypotension and Hypovolemia

Mild hypotension is one of the more common circulatory abnormalities seen in thePACU. Significant hypotension, however, is seen less frequently.

CAUSES

Postoperative hypotension is most often caused by hypovolemia. Cardiac dysfunction,such as heart failure, is a less common cause. The infrequent major crises (ie, severehypoxemia, anaphylaxis, transfusion reactions, drug reactions, sepsis, cardiactamponade, pulmonary emboli, or adrenal insufficiency) can also involve significanthypotension (Freeley & Macario, 2005).

Hypovolemia. Causes of hypovolemia include blood loss and evaporation (fluids arelost by evaporation when an operation requires body cavities to be open for longperiods). Urinary losses are sometimes not fully replaced with intravenous fluid. Inaddition, the body's reaction to the injury of surgery makes local blood vessels morepermeable, and body fluids leave the circulation and accumulate in tissue spaces, in theperitoneal space, and even inside the intestines (Ali, 2005).Cardiacdysfunction. Occasionally, cardiac dysfunction is the major cause ofpostoperative hypotension. The cardiac dysfunction (heart failure, dysrhythmia,myocardial infarction) can be a new problem caused by the intraoperative drugs or theconditions of surgery. More often, however, postoperative heart malfunctions areexacerbations of pre-existing heart problems.Spinal opioids. Epidural or intrathecal anesthesia, especially with an opioid, can causeneurogenic hypotension (Tarrac, 2006; Sherwood et al., 2008).




Hypotension

In the PACU, patients' blood pressures should be checked regularly. Mild hypotensionmeans a drop in blood pressure of less than 10% to 15% from the patient's baselinevalues. Significant hypotension means a drop of 20% to 30% in blood pressure values.

Hypovolemia

Hypovolemia in a postoperative patient can usually be recognized clinically by theoccurrence of a number of these signs:

TachycardiaDecreased radial pulseheightCool extremitiesNarrow pulse pressure (pulse pressure is the difference between the systolic anddiastolic blood pressurevalues)Poor skin turgorDry mucous membranesScanty, concentrated urineLethargySometimes, cyanosis

MANAGEMENT

Mild postoperative hypotension is a common finding, and it can usually be managed byregular monitoring. On the other hand, significant hypotension needs prompt treatment.Assuming there is a clear airway and adequate ventilation, oxygen is administered,fluids are increased, and when possible, the patient is put in the Trendelenburg position(Tarrac, 2006). Then the causes of the hypotension must be searched for and treated.

Meanwhile, if fluids do not improve the hypotension, then it may be necessary toadminister vasopressors. An anesthesiologist or critical care physician must be involvedin this and all further evaluations and treatments of postoperative hypotension (Walley,2005).

Tachycardia

CAUSES

Postoperative tachycardia can be a sign of a wide range of stressors, including pain,hypoxemia, hypercapnia, anemia, hypovolemia, and fever, or it can be component of adysrhythmia. In the PACU, pain and discomfort (eg, from an over distended bladder)are the most common causes of tachycardia.




Tachycardia is defined as ≥100 heartbeats/minute.

MANAGEMENT

When a PACU patient develops tachycardia, the nurse checks the patient's airway,oxygen saturation level, vital signs, volume signs (jugular venous fill level, urineoutput, peripheral pulses, capillary refill time), and bladder size. In addition, the nurseevaluates the patient's cardiac rhythm. Any problems are treated.

Persistent tachycardia can often be slowed with fluids, an opioid analgesic, or a beta-adrenergic blocker. All these measures need the consent of the attending physician(Tarrac, 2006).

Tachycardia may also be acomponent of a newly developed dysrhythmia. Mostdysrhythmias that appear in the PACU are the result of an underlying metabolic orcirculatory imbalance. When the physiologic imbalance is corrected, the dysrhythmiaand the tachycardia will usually disappear (Freeley & Macario, 2005).

Care of Circulatory Catheters

When patients come to the PACU with venous or arterial catheters, the admitting nurseshould check that all the catheters are still patent and in the correct locations. If acentral venous catheter was placed during the operation without its location havingbeen verified radiographically, the anesthesiologist will probably order a chest film inthe PACU to confirm the proper placement.

Arterial pressure catheters should be calibrated against the PACU's blood pressure cuff.During the patient's stay in the PACU, measurements made via the catheters should benoted alongside the values obtained from the PACU's usual monitors (Barone et al.,2004).

BODY TEMPERATURE PROBLEMS

Hypothermia and Shivering

It is estimated that more than half of all postoperative patients have hypothermia duringtheir stay in the PACU. Hypothermia means that the patient's central circulatorysystem has a core temperature of <36° C (<96.8° F). Core temperatures are most easilymeasured at the eardrum (Kiekkas et al., 2005d).

Hypothermia leads to shivering, which is a spontaneous and involuntary musculartremor. The muscular effort of shivering uses energy and oxygen, increases bloodlevels of lactic acid and carbon dioxide, and increases cardiac output. Intense shiveringwill increase the body's metabolic rate 4 to 5 times, and in some cases, shivering caneven produce hyperthermia of >38° C (>100.8° F).



On occasion, hypothermia and the metabolic stresses from shivering cause cardiacarrhythmias, myocardial ischemia, hypotension, coagulation problems (leading toexcess blood loss), metabolic acidosis, increased rates of infection, or slowed rates ofrecovery. These complications are more likely in patients with pre-existing heart, lung,coagulation, or immune system problems. Previously normotensive patients can alsodevelop hypertension from hypothermia.

These secondary complications are not common, however. In general, postoperativepatients who did not have pre-existing serious medical problems will not suffersecondary complications from mild hypothermia in the PACU (Kiekkas et al., 2005d;Sherwood et al., 2008).

CAUSES

Under anesthesia, the body's temperature regulating mechanisms are less responsivethan normal, and during surgery, the temperature of the central circulatory systemsometimes drops inappropriately. The highly volatile anesthetics used for generalanesthesia are well-known causes of hypothermia, but hypothermia can also result fromregional anesthesia if the patient is not kept warm. Some situations in which patientsare more likely to develop postoperative hypothermia are presented in the box below.

RI SK FACTORS FOR HYPOTHERM I A

Older adultLong surgeryOpen thoracic or open abdominal surgeryThyroid or adrenal deficiencyLean body

Source: K iekkas et al ., 2005d.


A PACU patient's core body temperature should be monitored regularly; the tympanicmembrane temperature correlates well with the core body temperature.

Shivering is a good clinical indicator of hypothermia. All voluntary muscles in the bodycan tremble during shivering, but shivering is most easily seen in the jaw muscles andin the shoulder muscles (Barone et al., 2004).

MANAGEMENT

Even when covered by a blanket, a hypothermic person cannot quickly increase theircore body temperature without using their muscles to generate heat. Shivering is thenormal way that an immobile person generates muscular heat, and hypothermic patientsin the PACU will involuntarily shiver to rewarm their bodies. Unfortunately, intenseshivering is metabolically demanding and can cause other complications in



postoperative patients. Therefore, PACU staff should remove the need for shivering byproviding external heat to warm hypothermic patients.

Forced-air convection warming systems(eg, Bair Hugger systems) are preferred forheating hypothermic patients. Second choices include heated blankets, warming lights,thermal ceilings, or increased room temperature. Warm intravenous fluids (or warmtransfused blood, when appropriate) will also help, as will warming the air used toventilate intubated patients. To ease shivering in patients while awaiting the effects ofexternal heat sources, small doses of meperidine (Demerol) can be given with caution.

Patients who are shivering should receive supplemental oxygen to compensate for theincreased oxygen their muscles are using (Barone et al., 2004; Freeley & Macario,2005; Morgan et al., 2006).

Malignant Hyperthermia

CAUSES

Malignant hyperthermia is a rare genetic disorder. Patients with this disease candevelop sudden severe muscle contractures when their bodies are exposed tosuccinylcholine or certain anesthetic gases (fluorinated ethers—isoflurane, halothane,enflurane, sevoflurane, or desflurane). The involuntary muscle contractures generateheat, and when malignant hyperthermia is triggered, a patient's body temperature canrise to >40° C (>104° F).


Malignant hyperthermia usually appears in the OR, but sometimes it first shows up inthe PACU. Patients with malignant hypothermia have rigid jaw muscles (spasms of themasseter muscles), metabolic acidosis, and, usually, tachycardia and tachypnea; feverdevelops later.

MANAGEMENT

If postoperative patients have the symptoms of malignant hyperthermia, PACU staffshould administer 100% oxygen and notify the anesthesiologist immediately (Barone etal., 2004).

BLOOD SUGAR ABNORMALITIES AND DIABETES

The stresses of surgery lead to increases in blood sugar levels, and when plasmaglucose concentrations remain higher than 180–200 mg/dl, patients tend to becomedehydrated. Patients with diabetes are unable to reduce episodic hyperglycemia withoutmedications; therefore, diabetics are susceptible to dehydration after surgery. Surgerycan unmask type2 diabetes in people with previously undetected disease, so all PACUpatientsshould have their blood glucose levels checked at least once.



At the other end of the spectrum, patients with certain metabolic problems, such as liverdisease, may not have sufficient stores of glycogen. For these people, the stresses ofsurgery can make them hypoglycemic.

Patients who are currently receiving intravenous hyperalimentation are a thirdpopulation at risk for unhealthy levels of blood sugar postoperatively. For these people,anesthesiologists must carefully balance the amount of carbohydrates given duringsurgery; in general, normal levels of intravenous sugars in the hyperalimentation fluidscan lead to postoperative hyperglycemia, while too low a level of intravenous sugarwill cause postoperative hypoglycemia (Barone et al., 2004).

Causes

The stresses of surgery cause the body to release cortisol and glucagon. Thesehormones raise the level of blood glucose.


Patients, such as diabetics, whose metabolism is not agile at handling changes in bloodsugar concentration should have their blood glucose levels monitored during their stayin the PACU. Patients who are at risk for type 2 diabetes (ie, people who are sedentary,middle-aged or older, and who are overweight, dyslipidemic, hypertensive, or with afamily history of diabetes) should have their blood glucose levels checked at least onceduring recovery. Blood glucose levels can be measured with a simple bedside fingerstick.

Management

Postoperative patients should maintain blood glucose levels lower than approximately200 mg/dl. Patients with higher levels of blood glucose need insulin, the type and doseof which should be determined by the patient's physician.

When giving insulin, there is always the danger of hypoglycemia; therefore, insulin isusually given with a concurrent intravenous drip of a dextrose solution. Insulin can alsocause hypokalemia, so potassium chloride is sometimes added to the intravenousdextrose drip. The patient's fluid levels and kidney functioning must be taken intoaccount when a patient's glucose level is being adjusted externally, and all decisionsmust be made by an attending physician.

At the same time, the hydration status is monitored for all postoperative patients withhyperglycemia. Fluid intake and output should be recorded (urinary catheters may beneeded) and serum electrolytes checked (Noble, 2005).

POSTOPERATIVE AGITATION AND DELIRIUM

As they are emerging from anesthesia, some patients become agitated, and occasionallya patient awakens confused or delirious.



Causes

AGITATION

Restlessness or agitation in a patient who is not fully awake can be a sign ofphysiologic problems. Therefore, when patients seem uncomfortable, nurses shouldlook for possible medical causes, including pain, hypoxemia, hypercapnia, acidosis,hypotension, hypoglycemia, and adverse drug reactions.

CONFUSION

Confusion and delirium are most common in older adults, in patients with pre-existingcerebrovascular disease or brain dysfunctions, and in patients who were very anxious orfearful preoperatively.Major surgery is more likely to trigger confusion or delirium than short procedures orones done under regional anesthesia.Certain medications are more likely to cause delirium; these include ketamine,anticholinergics, phenothiazines, barbiturates, and benzodiazepines.

Management

When mental disturbances appear, PACU staff should check vital signs, bladderdistention, the state of the surgical wound, serum electrolytes, blood glucose levels, andarterial gases. Any problems should be treated.

With no evidence of pain or serious physiologic problems, restlessness, agitation,confusion, and delirium are treated empirically. An effort should be made to re-orientthe patient. During this process, the staff should be patient, because it may be necessaryto wait for the residual levels of intraoperative medications to decrease sufficiently sothat the patient's brain can re-orient itself.

Intravenous midazolam (abenzodiazepine) can sometimes help to reduce a patient'sagitation. Very agitated patients may need soft restraints to avoid injuring themselves,disrupting intravenous lines, or blocking their own airways (Barone et al., 2004;Morgan et al., 2006; Sherwood et al., 2008).

DELAYED EMERGENCE

Patients usually emerge from anesthesia within 30 minutes after surgery. On occasion,however, the return to normal consciousness is delayed.

Causes

Most commonly, delayed emergence is due to lingering effects of anesthetics,sedatives, analgesics, or other medicines given in the course of the surgery. Oneexplanation for a delayed emergence is that the effects of these medicines have been



potentiated by drugs or alcohol that a patient ingested before the surgery. In addition,extreme hypothermia (<33° C, <91.4° F) will slow emergence.

On the other hand, an apparent "delayed emergence" may actually be an unconsciouspatient. The patient may have suffered a stroke, or the unconsciousness could be theresult of ametabolic problem, such as a very high or a very low blood glucoseconcentration.


When a patient has not awakened within the first half hour after surgery, there shouldbe a thorough search for possible causes.

Management

Any problems in vital signs, blood electrolytes, blood glucose, or arterial blood gasesshould becorrected. If this does not improve the patient's level of consciousness,pharmacologic tests are tried in an attempt to counteract surgical medicines; forexample:

Naloxone usually reverses persistent effects of opioidsFlumazenil usually reverses persistent effects of benzodiazepinesPhysostigmine partially reverses the effects of anticholinergics

The failure of these drugs to change the patient's level of consciousness should trigger aneurologic consult (Freeley & Macario, 2005; Morgan et al., 2006).

PART 4: Challenges in the Operation of a PACU

Challenges in the operation of a PACU include medication errors, accommodatingnon-postoperative patients, family visitation, admission delays, and discharge delays.

MEDICATION ERRORS

The fast and intense pace of a PACU during peak hours makes the staff susceptible tomistakes. The seriousness of the medication errors made in the PACU is second only tothose made in the OR.

LOCATIONS OF SERIOUS MEDICATION ERRORS IN HOSPITALSLocation Medication Errors Resulting in Harm

Operating room (OR) 7.2%

PACU 6.0%

Source: Hi cks et al ., 2007.



Location Medication Errors Resulting in HarmIntensivecare unit (ICU) 3.3%

Hospital, overall 1.3%Source: Hi cks et al ., 2007.

Causes

Nicks and colleagues (2007) identify four types of mistakes lead to most of themedication errors in PACUs:

Prescribingmistakes

◦ Physicians inaccurately filling out preprinted medication order forms◦ Physicians prescribing medicationscontraindicated by the patient's known

allergies or previous poor reactions

Dose or quantity mistakes

◦ Nursesmisprogramming patient-controlled analgesia (PCA) pumps◦ Nursesconfusing dosage weight with dosage volume (eg, giving 2 ml

instead of 2 mg)

Drug omission mistakes

◦ Physicians not ordering an antimicrobial when needed

Wrong-drug mistakes

◦ Nurses administering similar sounding or similar looking drugs (eg,morphine solution vs. hydromorphonesolution)

◦ Nurses retrieving the wrong drug from a common dispensing cabinet or tray(Nicks et al., 2007).

Reduction of Errors

Here are some practical suggestions to reduce PACU drug errors (Hicks et al., 2007):

Nurses should always do two checks of the medicine name against the prescribed nameand t wo checks of the actual dose against the prescribed dosage.For PCA pumps, each programmed parameter (analgesic name, bolus dose, lockoutinterval, dose limit, background infusion rate) should be checked t wice.Vials of liquid drugs should be labeled with the t otal weight of the drug and thet ot al volume of liquid in the vial. In other words, a vial label should read, "100 mgdrug X, total vol. = 10 ml, concentration = 10 mg/ml."Purchase single dose vials, ie, using vials with a premeasured single dose is better thanusing vials from which single doses must be extracted and measured by a nurse.Precalculated dose vs. weight charts should be available for medicines to avoidcalculation errors.



Pharmacists should be directly involved in stocking and organizing drugs in the PACU.Medication errors should be reported to the PACU director in the team spirit of helpingall the staff to learn and improve.

ACCOMMODATING NON-POSTOPERATIVE PATIENTS

Like ICU nurses, PACU nurses are trained to monitor patients continuously and to bealert for developing crises. PACUs are usually adjacent to an OR, are sufficientlystaffed so that nurses can devote full time to individual patients, and have the capabilityof managing patients on mechanical ventilation. For these reasons, PACUs are among asmall group of hospital units equipped to care for and monitor patients at risk forsuddenly developing life-threatening conditions.

Due to their special capabilities, PACUs are sometimes called on to care for non-postoperative patients. In some hospitals, PACUs play a broad role, being used as:

Overflow beds for filled ICUsBeds for medical patients who need mechanical ventilationTemporary wards for patients who require preoperative stabilizationProtected environments for anesthesiologic procedures such as the insertion of centralvenouscathetersTemporary intensive care units for monitoring patients after invasive radiologic andthrombolytic procedures (Kiekkas et al., 2005b)

However, the admission of non-postoperative patients puts a strain on PACUs. Theseoutside patients are a varied group and they come at unpredictable times. PACUstaffing that had been planned for a particular postoperative schedule cannot alwayscover the added patients. Non-postoperativepatients may need frequent lab tests, andsome may need to be cared for at greater length than postoperative patients. Moreover,the flow of information—anesthesiologist to PACU nurse and PACU nurse toanesthesiologist—to which the PACU staff is accustomed, is not the way information istransmitted for most non-postoperative patients (Saastamoinen et al., 2007).

A number of specific measures have been suggested to help PACUs cope with theseadded responsibilities. First, it is important that the PACU director, the directors of theICUs and the ED, and the hospital management have an explicit agreement as to thepriorities and essential responsibilities of the PACU. The agreement should spell outwhich services (if any) can plan to use the PACU for minor procedures or formonitoring patients after nonsurgical invasive procedures (ASPAN, 2003a).

Second, PACU directors need to be aware that, occasionally, patients with complexmedical problems will have to be admitted to the PACU rather than to an ICU.Therefore, some PACU nurses should regularly rotate through the ICU to increase theirfamiliarity with the additional skills needed to care for critically ill patients. Also, theanesthesiology department should organize in-house courses to prepare PACU nursesfor non-postoperative patients who may be admitted to their PACU.



Third, if it appears that a PACU will regularly be dealing with critically ill or medicallycomplicated patients, the hospital should consider establishing an additional, somewhatdifferently oriented unit. Toward this end, some hospitals have created short-term orovernight ICUs that are specifically organized and staffed to cope with bothpostoperative or non-postoperative patients who need ICU-level care for anintermediate period of between 6 and 24 hours (Hodge, 2006). These units fill the gapbetween the very-short-term PACU and the longer-term ICU.

FAMILY VISITATION

The American Society of PeriAnesthesia Nurses (ASPAN) points out that allowingfamily members to visit patients in Level I (immediately postoperative) PACUs canbenefit both the patient and the family (ASPAN, 2003b). The ASPAN recommends thatPACUs try to accommodate family visits within these guidelines:

Visits take place only when the PACU staff agrees that it is appropriate for both thepatient and thenurses.Visitors are given guidance on safe behavior in the PACU.Visitors are instructed on respecting the confidentiality of all patients in the PACU.There is a formal visitation program that uses personnel other than the on-duty PACUstaff to oversee the timing of visits and the preparatory education of visitors.

ADMISSION DELAYS

Delays in PACU admissions are inevitable. The day's surgery schedule can be squeezedby emergencies and delayed by complications. Likewise, the availability of PACU bedsand nurses is limited by slow recovery times, medical complications, and bottlenecks inthe discharge process. Therefore, asurgeon will occasionally complete a procedurebefore there is a space for the patient in the PACU.

Even with artful scheduling of surgeries and PACU nurses, it is important to have apreplanned protocol for dealing with delayed admissions to the PACU. Among all thepossible solutions, the safest course is usually for the operating anesthesiologist tocontinue to care for the patient in the operating room until a PACU bed and nursebecome available (Dexter et al., 2006).

DISCHARGE DELAYS

Patient discharges are one of the most inefficient parts of the PACU process. One largestudy found that the average length of a patient's stay in the PACU was 95 minutes,although patients were ready for discharge in an average of 71 minutes. Thesedischarge delays tie up PACU beds and nurses, and the effect propagates back, causingPACU admission delays, which then slow the surgical schedule (Kiekkas et al., 2005a).Because of their additive effects, PACU discharge delays get longer as the dayprogresses.



Most discharge delays in the PACU are not due to medical problems. Instead, slowdischarges are usually due to logistical problems in transferring PACU patients to thenext stage in their care (Kiekkas et al., 2005a). The reasons for delay include manytypical hospital inefficiencies and miscommunications; specifically, the followingthings are not always available when needed for a patient being discharged from thePACU:

Transport assistanceA physician to authorize or sign discharge formsA bed in the receiving unitNurses in the receiving unitTest results (Freeley & Macario, 2005)

These problems are inherent in all large hospitals: hospitals are places where manycomplex activities are carried out simultaneously and where efficiencies must takesecond place to emergencies and patient care. Nonetheless, looking at the details ofPACU delays, Kiekkas and colleagues (2005a) have pointed to two improvements thatare feasible and that may have a significant effect.

First, they point out that little attention is usually paid to the scheduling of transportersfor PACU discharges, and organizing the transport staff can reduce discharge delays.Second, Kiekkas and colleagues suggest that the PACU staff adopt a policy of notifyingthe receiving unit 15 to 30 minutes before the anticipated discharge of a patient; thiswould increase the probability that the receiving unit will be ready when the patient isdischarged.

PART 5: Summary

THE PACU

During their recovery from anesthesia, patients must be monitored until they are awakeand their vital signs are stable. Most patients have an easy transition from theanesthetized state to stable consciousness. Nonetheless, in an era of complex majorsurgeries done on increasingly compromised patients, emergence from anesthesiasometimes comeswith life-threatening complications. For these reasons, recoveryrooms, which were once postsurgical rest stations, are now short-term ICUs calledpostanesthesia care units, or PACUs.

The PACU Staff

The PACU is a specialized division of the anesthesiology department. A PACU isdirected by an anesthesiologist, and it is staffed by nurses who are skilled inrecognizing and managing airway problems, hypoxemia, hypotension, hypothermia,pain, nausea, and vomiting, as well as the lingering effects of anesthesia and musclerelaxants. PACU nurses must cope with bleeding from surgical sites, hypertension,dysrhythmias, myocardial infarctions, and altered mental states. The nurses carry out



these specialized medical tasks in a setting where, at the same instant, there can bepatients who are unconscious, emerging from sedation, suffering from acute respiratoryor circulatory complications, being admitted, and being discharged.

Admission to the PACU

Unless the anesthesiologist specifically orders otherwise, all anesthetized patientsshould be sent to a PACU for recovery. After a surgical procedure has been completed,the anesthesiologist accompanies the patient to the PACU. There, the anesthesiologistgives a verbal report to a PACU nurse, rechecks the patient, and leaves contactinformation for the nurse. The nurse usually gives the patient oxygen and then sets up amonitoring schedule for checking the patient's vital signs, blood oxygen saturation,level of consciousness, degree of pain, and degree of nausea.

Stay in the PACU and Discharge

During the patient's stay in the PACU, the attending nurse manages, or gets help for,any complications that develop. Life-threatening complications in the PACU are, ingeneral, infrequent. Nonetheless, PACU nurses regularly deal with postoperativenausea and vomiting (PONV), postoperative pain, respiratory problems, cardiovascularproblems, body temperature problems, blood sugar level abnormalities, agitation,delirium, and delayed emergence.

On average, aPACU stay lasts somewhat more than an hour. The discharge processbegins when the PACU nurse is convinced that the patient is alert and has vital signsthat have been stable for 30 minutes or more. At this point, the nurse contacts theanesthesiologist, who then discharges the patient. Patients who are going to anothercare unit are turned over to a hospital nurse, who gets a report, medical orders, andfurther instructions. Patients who are going home are given written instructions andguidelines and must be accompanied by a responsible adult.

Challenges for the PACU Staff

Running an efficient PACU is a challenge. There are inevitable medication errors,questions about family visitation, the pressure to admit non-postoperative patients, andlogistical delays in patient discharges.

One of the most common difficulties is admission delays. At peak times, the patientload can fully occupy a PACU's beds and its staff, and any patients just completingsurgery may have to remain in the OR temporarily. Such delays in admission to thePACU can be minimized by arranging each day's surgical schedule to make it likelythat the completion times of the operations will be staggered.

Nonetheless, even elective surgery times cannot be predicted accurately, whileemergency surgeries will always be unpredictable. Therefore, PACUs must build someflexibility into their staffing rosters. It is ideal, for example, to always have an extraPACU nurse on duty elsewhere in a noncritical service so that they can be paged to



help if the PACU should suddenly become busy. In addition, PACUs should have asafety capacity, ie, more available beds than would be necessary for their normal levelof use (Weissman, 2005).

PART 6: Telephone Counseling

Health professionals who advise patients over the telephone should knowstraightforward answers to basic questions. Here are some common questions andsuggested answers about the postsurgical recovery room.

Informational Questions (ASA, 2008)

What will happen after my surgery?

Right after your surgery, you will need to recover from the anesthesia. If you hadgeneral anesthesia, you will have been asleep, and during your recovery you will slowlywake up. If you have had local or regional anesthesia, you may be groggy, or evenasleep, and you will slowly wake up and get your thinking back to normal during therecovery period. In all cases, your recovery will take place in a special medical unitcalled a postanesthesia care unit, or PACU for short.

What is a PACU? What happened to the recovery room?

The PACU is another name for the recovery room. Many hospitals changed thename as medical care became more advanced for patients after their surgeries.However, even though hospitals call these special-care units PACUs, many people stillrefer to them as recovery rooms.

PACUs areset up to take care of sicker patients, patients who would have had to go toan intensive care unit in the old days. The nurses and doctors in today's PACUs havespecialized training so that they can care for the rare serious emergencies that happenafter surgery as well as for the normal recovery that most patients go through.

What happens in a PACU?

After surgery, your anesthetics are stopped, and, to help you recover, newmedications are often given to speed your return to normal. Nonetheless, you still needtime to wake up and time for your body to readjust to working normally again. Yourrecovery takes place in a PACU.

At the end of your surgery, while you are still asleep, your anesthesiologist will takeyou to the PACU. The anesthesiologist will check your condition and give the nursesinstructions for your care during your recovery.



In the PACU, nurses will continually watch your temperature, your heart rate, yourblood pressure, your breathing, and your oxygen levels. Usually, your body will getback to normal smoothly. If there are any problems, however, the PACU nurses willquickly readjust things by warming you, giving you oxygen, or administeringmedicines.

After you wake up and before you are fully recovered, you may be queasy or you mayhave pain. Somediscomfort is normal, and the PACU nurses will give you medicines toease any problems.

Are there any doctors in the PACU?

Your anesthesiologist remains in charge of your care while you are recovering, andwill determine when you are able to leave the PACU. In many PACUs, when things arerunning smoothly, nurses handle all the details of your care. The nurses are constantlyin contact with doctors, and a doctor will come immediately if there are any problems.

Could I die from anesthesia?

Deaths from the anesthesia itself are very uncommon. Although the data is notprecise, it has been estimated that, in the United States, the risk of dying from theanesthesia alone is about 1 in 50,000.

Any serious problems that people have after surgery are usually the result of theoperation or of the combination of the surgery and the person's pre-existing medicalconditions. Your specific risk of running into trouble after surgery depends on the typeof operation and on your other illnesses. Talk with your surgeon and youranesthesiologist before your surgery, and ask about the risks for your particularsituation.

Will I have a tube in my throat when I wake up?

This depends on the type of surgery. Patients usually have a breathing tube (calledan "endotracheal tube") in their throats when they are asleep under general anesthesia.By the time they wake up, however, the tube has been removed.

Will the breathing tube leave me with a sore throat?

The breathing tube (the endotracheal tube) used during general anesthesia maygive you a mild sore throat when you wake up. It can also make you hoarse. Thesoreness and hoarseness usually go away on their own in a few days, without anymedicines or treatment.

Will I throw up in the PACU?



Many people feel queasy after they wake up from general anesthesia, but mostpeopledon't throw up. Don't be shy about telling your PACU nurses if you feeluncomfortable, because they have medicines that will make your nausea less severe.

Will I have pain after surgery?

This depends on the type of surgery. It's helpful to ask your surgeon and youranesthesiologist before the operation, so you will be prepared for any pain you mighthave when you wake up.

If you do have pain, your anesthesiologist and the PACU nurses will use whatevermedicines are necessary to reduce it. Pain serves no good purpose after surgery, anddoctors do not want you to have severe or even moderate pain. If you are having painduring your recovery, don't hesitate to ask the PACU nurses for pain medicine.

Will they give me narcotics after my surgery, and could I get addicted?

Narcotics, such as morphine, are very effective for reducing pain. Youranesthesiologist and the PACU nurses will give you the best possible medicines toreduce any pain you experience. And don't worry—people given narcotics in the PACUrarely get addicted.

Will I dream while under anesthesia?

Most people do not recall having dreams under general anesthesia.

Can I have visitors in the PACU?

Visitors can make patients feel better after their surgery, but some PACUs are toobusy or too crowded to allow visitors. On the other hand, many PACUs do haveprograms that let family members visit patients who are awake. Check with yourhospital in advance to find out whether it may be possible for a family member orfriend to visit with you during your recovery.

When can I leave the PACU?

Beforeyou can leave the PACU, your anesthesiologist will want to be certain thatyou have safely recovered. You should be awake and alert, and your body should berunning smoothly on its own. This takes at least a half hour. In general, however,patients usually stay in the PACU for about an hour.

What happens after I 'm discharged from the PACU?



After major surgery, you need to be watched and cared for in the hospital at leastfor a day or two. If you are having major surgery, you will be wheeled back to yourhospital room after your stay in the PACU.

Outpatients are often sent home after being discharged from the PACU. If you aregoing home on the same day as your surgery, a responsible adult must come to thehospital and take you home. You will get instructions on how to care for yourself, andthe hospital will give you a number to call with any questions. For the next 24 hours,you shouldn't drive or do anything potentially dangerous, and you shouldn't make anyimportant decisions during that time. An adult should stay with you the first night afteryour surgery.

How soon will I feel normal after anesthesia?

Recovery from the surgical procedure varies according to the type of operation. Asfor recovery from the anesthesia itself, count on needing 24 hours.

Small amounts of the anesthetic drugs will remain in your body for at least a day afteryour surgery. Most patients notice no effect from these residual drugs, but some peopleare especially sensitive to them and report feeling mildly affected for about a day aftertheir operation. While recovering from the anesthesia during the first day after yoursurgery, you should relax and not do serious or important things.

RESOURCES

American Academy of Pain Managementhttp://aapainmanage.org

American Society of Anesthesiologistshttp://www.asahq.org

American Society of PeriAnesthesia Nurseshttp://www.aspan.org

AORN, Association of Perioperative Registered Nurseshttp://www.aorn.org

Medical Hyperthermia Association of the United Stateshttp://medical.mhaus.org/

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