ATLAS HOSPITAL

P.O BOX 1101, Postal Code : 133, MBD East,

RUWI. Sultanate Of Oman.

Phone: 24811706

Fax:24811812

Email: atlashospital@gmail.com

12/4/2015 3:47:40 PM

HOSPITALS

Life Long Health Care

www.AtlasEra.com

During The Presentation

PLEASE:

• Put cell-phones on silent/vibrate mode.

• Take emergency calls outside.

• Maintain silence.

HOSPITALS

Post- Anaesthesia Care

(PAC)

DR RAJESH T EAPEN

ANESTHESIOLOGIST

ATLAS HOSPITAL, RUWI

Introduction

Recovery from anesthesia can range from

completely uncomplicated to life-threatening.

Must be managed by skilled medical and

nursing personnel.

Anesthesiologist plays a key role in optimizing

safe recovery from anesthesia

Must be carried out in a well planned, protocol

based fashion

2/4/2015 3:47:52 PM 5

PAC

Definition

It is the specialized care given

to the patients who have

undergone anaesthetic

management, by a team of

well trained professionals, in a

specially designed, equipped

and designated area of the

hospital

2/4/2015 3:47:52 PM 6

PURPOSES

To enable a successful and faster recovery of the patient post operatively.

To reduce post operative mortality rate.

To reduce the length of hospital stay of the patient.

To provide quality care service.

To reduce hospital and patient cost during post operative period.

2/4/2015 3:47:53 PM 7

PAC Vs. Post operative care

PAC is provided to

anyone who has undergone anaesthesia

anaesthesia might not be for a surgical

procedure

patients undergoing ECT, Narco analysis

patients under going Endoscopies

+

all the patients who have undergone

surgeries

2/4/2015 3:47:53 PM 8

PACU

Definition : It is the

Specially designated

Specially designed

Specially located

Specially staffed

Specially equipped

for a

Specific purpose !

2/4/2015 3:47:53 PM 9

History of the PACU Methods of anesthesia have been available for more

than 160 years, but the PACU has only been common for the past 70 years.

One can trace it to “Lady of the lamp”: F. N.

1920’s and 30’s: several PACU’s opened in the US and abroad.

It was not until after WW II that the number of PACUs increased significantly. This was due to the shortage of nurses in the US.

In 1947 a study was released which showed that over an 11 year period, nearly half of the deaths that occurred during the first 24 hours after surgery were preventable.

1949: having a PACU was considered a standard of care.

2/4/2015 3:47:55 PM 10

PACU Location Should be located close to the Operating Theater

Immediate access to x-ray, blood bank, blood gas and clinical

labs.

An open ward is optimal for patient observation, with at least

one isolation room.

Central nursing station.

Requires good ventilation, because the exposure to waste

anesthetic gases may be hazardous.

National Institute of Occupational Safety (NIOSH) has

established recommended exposure limits of 25 ppm for

nitrous oxide and 2 ppm for volatile anesthetics.

2/4/2015 3:47:55 PM 11

Design of PACU

Size:

Ideal 1.5 PACU bed for every Operating Room

120 square foot per patient

Minimum of 7 feet between beds

Facilities:

Fowler’s cot with side rails

Piped Oxygen, Vacuum and Air

Multiple electrical outlets

Large doors

Good lighting

Isolation for Immuno-compromised patients

2/4/2015 3:47:55 PM 12

PACU

PACU should be sound

proof, painted in soft colour,

isolated and these features

will help the patient to

reduce anxiety and promote

comfort.

2/4/2015 3:47:55 PM 13

2/4/2015 3:47:56 PM 15

2/4/2015 3:47:56 PM 16

PACU Staffing

One nurse to one patient for the first 15

minutes of recovery.

Then one nurse for every two patients.

The anesthesiologist responsible for the

anesthetic remains responsible for managing

the patient in the PACU.

Adequate no. of ancillary staff, such as

technicians, ward boys and female attenders.

2/4/2015 3:47:56 PM 17

PACU Equipment

Multi-parametric monitors (Automated BP,

pulse ox, ECG) and intravenous supports

should be located at each bed.

Area for charting, bed-side supply storage,

suction, and oxygen flow meter at each bed-

side.

Immediately available - Emergency

equipment, Crash cart, Defibrillator.

2/4/2015 3:47:56 PM 18

2/4/2015 3:47:56 PM 19

Routine Post-Anaesthesia Care

Criteria for shifting from

OR---to---PACU

Haemo dynamic stability

Clinical evaluation and

complete recovery from

NM blockade

Maintenance of Oxygen

Saturation

Normothermia

2/4/2015 3:47:56 PM 20

PACU Standards

1. All patients who have received general anesthesia, regional anesthesia, or monitored anesthesia care should receive post-anesthesia management.

2. The patient should be transported to the PACU by a member of the anesthesia care team that is knowledgeable about the patient’s condition.

3. Upon arrival in the PACU, the patient should be re-evaluated and a verbal report should be provided to the nurse.

4. The patient shall be evaluated continually in the PACU.

5. Anaesthesiogist, concerned is responsible for discharge of the patient.

2/4/2015 3:47:56 PM 21

PHASES OF POST OP UNIT

Two phases-

Phase I

Phase II

2/4/2015 3:47:56 PM 22

Phase I

It is the immediate recovery phase and requires intensive nursing care to detect early signs of complication.

Receive a complete patient record from the operating room which to plan post operative care.

It is designated for care of surgical patient immediately after surgery and patient requiring close monitoring

2/4/2015 3:47:56 PM 23

Phase II

Care of the surgical patient who has been transferred from the Phase I post op unit.

Patient requiring less observation and less nursing care than Phase I

This phase is also known as Step down or progressive care unit.

2/4/2015 3:47:56 PM 24

Admission Report

Preoperative history

Intra-operative factors:

Procedure

Type of anesthesia

Estimated Blood Loss (EBL)

Urine output

Assessment and report of current status

Post-operative instructions

2/4/2015 3:47:56 PM 25

Postoperative Pain Management

Intravenous opioids

Diclofenac, I.V. Paracetamol and anti-

inflammatory drugs

Midazolam for anxiety

Epidural : LAAs and their adjuvants

Regional analgesic blocks

PCA (Patient controlled analgesia) and PCEA

2/4/2015 3:47:56 PM 26

2/4/2015 3:47:56 PM 27

2/4/2015 3:47:56 PM 28

2/4/2015 3:47:56 PM 29

2/4/2015 3:47:57 PM 30

2/4/2015 3:47:57 PM 31

NURSING MANAGEMENT IN POST

OP UNIT

To provide care until the

patient has recovered from

the effect of anesthesia.

Assessing the patient

Monitor vitals-pulse volume

and regularity, depth and

nature of respiration.

Assessment of patient’s O2

saturation.

Skin colour.

2/4/2015 3:47:57 PM 32

KEEP MONITORING VITALS

2/4/2015 3:47:57 PM 33

Check the level of consciousness.

Ability to respond to commands.

2/4/2015 3:47:57 PM 34

MAINTAIN INTAKE AND OUTPUT

2/4/2015 3:47:57 PM 35

Protect airway

By proper positioning of patient’s head.

By clearing airway.

Oxygen therapy.

Pharyngeal obstructioncan occur when the patient lies on the back as there are chances for

tongue to fall back.

2/4/2015 3:47:57 PM 36

Maintaining IV Stability

Hypovolemic shock: can be avoided by timely administration of IV Fluids, blood and blood products and medication.

Replacement of fluids.[colloids and crystalloids]

Monitor intake and output balance.

2/4/2015 3:47:57 PM 37

ASSESSMENT OF THE SURGICAL SITE

Hemorrhage

It is a serious complication of surgery that can result in death.

It can occur in immediate post operatively or up to several days after surgery.

If left untreated cardiac output decreases and blood pressure and Hblevel will fall rapidly.

2/4/2015 3:47:57 PM 38

Blood transfusion if necessary.

The surgical site + incision should always be inspected.

If bleeding- pressure dressing placed.

If the bleeding is concealed, the patient is taken in OR for emergency exploration of concealed hemorrhage in body cavity.

2/4/2015 3:47:57 PM 39

KEEP THE PATIENT WARM

Use warmer(Bair

Hugger) blankets

Use warm lights

2/4/2015 3:47:58 PM 40

Relieving pain +Anxiety Administer opioid

analgesia as per

Doctor’s order.

Epidural analgesia.

NSAIDS.

Psychological support to

relieve fear+To give

support.

2/4/2015 3:47:58 PM 41

Post Operative Complications

Nausea and Vomiting

Respiratory Complications

Failure to Regain Consciousness

Circulatory Complications

Fever

2/4/2015 3:47:58 PM 42

Controlling Nausea + Vomiting

This is common problem in post operative period.

Medication can be administered as per doctor’s order.

Example:

Inj Metoclopramide

Inj Ondansetron

(Emeset /Zofran)

2/4/2015 3:47:58 PM 43

2/4/2015 3:47:58 PM 44

2/4/2015 3:47:58 PM 45

2/4/2015 3:47:58 PM 46

Discharge criteria from PACU

Neither an arbitrary time limit nor a discharge

score can be used to define a medically

appropriate length stay in the PACU accurately

All patients must be evaluated by

anesthesiologist/trained staff prior to discharge

from PACU

Criteria for discharge developed by the

Anesthesia department

Criteria depends on where the patient is sent –

ward, ICU, home

2/4/2015 3:47:58 PM 47

Discharge criteria from PACU

Easy arousability

Full orientation

Ability to maintain & protect airway

Stable vital signs for at least 15 – 30

minutes

The ability to call for help if necessary

No obvious surgical complication (active

bleeding)

2/4/2015 3:47:58 PM 48

Discharge From the PACU

Standard Aldrete Score: Simple sum of numerical values assigned to

activity, respiration, circulation, consciousness, and oxygen saturation.

A score of 9 out of 10 shows readiness for discharge.

Post-anesthesia Discharge Scoring System: Modification of the Aldrete score which also

includes an assessment of pain, N/V, and surgical bleeding, in addition to vital signs and activity.

Also, a score of 9 or 10 shows readiness for discharge.

2/4/2015 3:47:58 PM 49

ALDRETE SCORE Post-Anesthesia Score

A total discharge score of 8-10 is necessary

Post-Anesthesia Score

PRE-ANESTHESIA VITAL SIGNS/SOURCE TIME ADM 15" 30" 45" 1' 2' 3' 4' DISCHARGE

SYSTOLIC BP 20% OF PRE-ANESTHETIC LEVEL 2

CIRCULATION 20-50% 1 > 50 0 FULLY AWAKE 2 CONCIOUSNESS

AROUSABLE ON CALLING 1

NOT RESPONDING 0 WARM, DRY SKIN W/ PREPROCEDURAL

COLORING 2

COLOR PALE, DUSKY, BLOTCHY, JAUNDICED, OTHER 1

CYANOTIC 0 ABLE TO DEEP BREATHE & COUGH FREELY

2

RESPIRATION DYSPNEA OR LIMITED BREATHING APKEIC 1

0 ABLE TO MOVE 4 EXTREMITIES 2 ACTIVITY ABLE TO MOVE 2 EXTREMITIES 1 ABLE TO MOVE 0 EXTREMITIES 0 COMMENTS TOTAL

2/4/2015 3:47:58 PM 50

Aldrete Score

Activity Respiration Circulation Consciousness Oxygen

Saturation

2: Moves all

extremities

voluntarily/ on

command

2:Breaths deeply

and coughs

freely.

2: BP + 20 mm of

pre-anesthetic

level

2:Fully awake 2: Spo2 > 92%

on room air

1: Moves 2

extremities

1: Dyspneic,

shallow or limited

breathing

1: BP + 20-50 mm

pre-anesthetic

level

1: Arousable on

calling1:Supplemental

O2 required to

maintain Spo2

>90%

0: Unable to

move

extremities

0: Apneic 0: BP + 50 mm of

preanestheic level

0: Not responding 0: Spo2 <92% with

O2

supplementation

2/4/2015 3:47:58 PM 51

2/4/2015 3:48:01 PM 52

Interpretation of Aldrete’s score

Lowest score = 0 – 2

Score for patient to be shifted to next level of

care = 9

Since some patients on arrival to PACU will meet the

score of 8, it is very illogical to fix a number for

shifting the patient

Ideally it should be decision of the Anesthesiologist

regarding the shifting from the PACU to next level of

care taking into account the anesthetic plan & the

drugs given intra-operatively as well as in PACU

Post-anesthesia Discharge Scoring

System (PADSS)Vital Signs

(BP and

Pulse)

Activity Nausea and

Vomiting

Pain Surgical

Bleeding

2: Within 20% of

preoperative

baseline

2: Steady gait,

no dizziness

2: Minimal: treat

with PO meds

2: Acceptable

control per the

patient;

controlled with

PO meds

2: Minimal: no

dressing

changes

required

1: 20-40% of

preoperative

baseline

1: Requires

assistance

1: Moderate:

treat with IM

medications

1: Not

acceptable to the

patient; not

controlled with

PO medications

1: Moderate: up

to 2 dressing

changes

0: >40% of

preoperative

baseline

0: Unable to

ambulate

0: Continues:

repeated

treatment

0: Severe: more

than 3 dressing

changes

2/4/2015 3:48:01 PM 53

Discharge from the Post Operative Unit

A patient remains in the post op unit, until the patient has fully recovered from anesthesia.

Following measures are used to determine the patient ready for

discharge from post operative unit:-

Stable vital signs

Orientation to Person, Place

Time or events

Adequate oxygen saturation level.

Urine out put at least 30ml/hour

Minimal pain.

Adequate respiratory function.

Aldrete score more than ‘ 9 ‘

2/4/2015 3:48:01 PM 54

Teaching, Patient Self Care

Expected out comes

Immediate post

operative changes

Written instructions like

Wound care

Activity+dietary

recommendation

Medications

Follow up

2/4/2015 3:48:01 PM 55

Safe guidelines for discharging to

home after ambulatory surgery

Patient should be able to stand & take a few

steps ( sit on bed if C/ I for standing)

Should be able to sip fluids

Should be able to urinate

Should be able to repeat post-operative

management

Should be able to identify the escort

(cognitive function)

2/4/2015 3:48:01 PM 56

Summary & Conclusion

Anaesthesia is becoming very sophisticated!

PAC is an absolutely essential care given by a

team of professionals!!

Anaesthesiologists and Trained nursing staff

are the most important members of PACU!!!

Thorough understanding of pathophysiology of

this period is very essential!!!!

With a well organized PACU, one can prevent

lot of post-operative morbidity & mortality!!!!!!

2/4/2015 3:48:01 PM 57

2/4/2015 3:48:01 PM 58