1. 1. DR. AFTAB
2. 2. Introduction Recovery from general anesthesia is a time of great physiological stress for many patients. Emergence from general anaesthesia should ideally be smooth and gradual awakening in a control environment. It often begins in the operating room or during transport to the recovery room and frequently characterized by complications. Even patients receiving spinal or epidural anaesthesia can experience marked decrease in blood pressure during transport. 2
3. 3. The Standards for Postanesthesia Care I. All patients who have received general anesthesia, regional anesthesia or monitored anesthesia care shall receive appropriate post anesthesia management. II. A patient transported to the PACU shall be accompanied by a member of the anesthesia care team who is knowledgeable about the patient's condition. The patient shall be continually evaluated and treated during transport with monitoring and support appropriate to the patient's condition. 3
4. 4. III. Upon arrival in the PACU, the patient shall be re- evaluated and a verbal report provided to the responsible PACU nurse by the anesthesia care team who accompanies the patient. IV. The patient's condition shall be evaluated continually in the PACU. The patient shall be observed and monitored by methods appropriate to the patient's medical condition. Particular attention should be given to monitoring oxygenation, ventilation, circulation, level of consciousness and temperature. V. Anaesthesiologist is responsible for the discharge of the patient from the postanesthesia care unit 4
5. 5. History of the PACU Methods of anesthesia have been available for more than 160 years, the PACU has only been common for the past 50 years. 1920s and 30s: several PACUs opened in the US and abroad. It was not until after WW II that the number of PACUs increased significantly. This was do to the shortage of nurses in the US. In 1947 a study was released which showed that over an 11 year period, nearly half of the deaths that occurred during the first 24 hours after surgery were preventable. 1949: having a PACU was considered a standard of care. 5
6. 6. 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 managing the patient in the PACU. 6
7. 7. PACU Location Should be located close to the operating suite. Immediate access to x-ray, blood bank, blood gas and clinical labs. Should have 1.5 PACU beds per operating room used. An open ward is optimal for patient observation, with at least one isolation room. Central nursing station. Piped in oxygen, air, and vacuum for suction. Requires good ventilation. 7
8. 8. PACU in ideal set up 8
9. 9. PACU Equipments Automated BP, pulse ox, EKG, and intravenous supports should be located at each bed. Area for charting, bed-side supply storage, suction, and oxygen flow meter at each bed-side. Capability for arterial and CVP monitoring. Supply of immediately available emergency equipment. Crash cart. Defibrillator. 9
10. 10. Admission Report Preoperative history Intra-operative factors : Procedure Type of anesthesia U/O Assessment and report of current status Post-operative instructions 10
11. 11. ROUTINE RECOVERY General Anesthesia Airway patency, vital signs, and oxygenation should be checked immediately on arrival. Subsequent B.P, P.R , and R.R measurements are routinely made at least every 5 min for 15 min or until stable, and every 15 min thereafter. Pulse oximetry should be monitored continuously in all patients recovering from general anesthesia, until they regain consciousness. 11
12. 12. Neuromuscular function should be assessed clinically, eg, head-lift. At least one temperature measurement should also be obtained. Additional monitoring includes pain assessment (eg, numerical or descriptive scales), the presence or absence of nausea or vomiting, and fluid input and output including urine flow, drainage, and bleeding. 12
13. 13. All patients recovering from general anesthesia should receive 3040% oxygen during emergence because transient hypoxemia can develop even in healthy patients. Patients at increased risk for hypoxemia, should continue to be monitored with a pulse oximeter even after emergence and may need oxygen supplementation for longer periods. Arterial blood gas measurements can be obtained to confirm abnormal oximetry readings. 13
14. 14. Oxygen therapy should be controlled in patients of COPD or history of CO2 retention. Patients should generally be nursed in the head-up position whenever possible to optimize oxygenation. Deep breathing and coughing should be encouraged periodically. 14
15. 15. Regional Anesthesia Pt. heavily sedated or hemodynamically unstable following regional anesthesia should also receive supplemental oxygen in the PACU. Sensory and motor levels should be periodically recorded following regional anesthesia Precautions in the form of padding or repeated warning may be necessary to prevent self-injury from uncoordinated arm movements following brachial plexus blocks. 15
16. 16. Blood pressure should be closely monitored following spinal and epidural anesthesia. Bladder catheterization may be necessary in patients who have had spinal or epidural anesthesia for longer than 4 h. 16
17. 17. Post op Complications 1. Pain 2. PONV 3. Delirium & emergence excitement 4. Shivering & hypothermia 5. Respiratory complications 6. Circulatory complications 7. Renal dysfunction 17
18. 18. (1)Pain Post-operative pain management should be an essential and integral part of the care given to the patient. A major postoperative pain is defined as the pain that could endanger life if inadequately relieved, and for which more vigorous and effectives treatments may be justified although carrying risk. 18
19. 19. In day care surgery, inadequate treatment of pain from a relatively trivial insult may cause an unplanned hospital admission. In hand surgery, inadequate treatment of pain may hinder mobilization function. After Caesarean section, a mothers pain may prejudice the bonding with her newborn child. 19
20. 20. Postoperative pain management options 1)Cognitive behavioral interventions: such as relaxation, distraction, ; these can be taught preoperatively & can reduce pain, anxiety, & the amount of drugs needed for pain control. 2)Systemic administration of nonsteroidal anti- inflammatory drugs (NSAIDs) or opioids using the traditional as needed schedule or around-the-clock administration 3)Patient controlled analgesia (PCA), usually meaning self-medication with intravenous doses of an opioid; this can include other classes of drugs administered orally or by other routes. 20
21. 21. 4)Spinal or Epidural analgesia, usually by means of an epidural opioid and/or local anaesthetic injected intermittently or infused continuously. 5)Intermittent or continuous local neural blockade (examples of the former include intercostal nerve blockade with local anaesthetic or cryoprobe; the latter includes infusion of local anaesthetic through an interpleural catheter) 6) Physical agents such as massage or application of heat or cold. 7)Electroanalgesia such as transcutaneous electrical nerve stimulation (TENS) 21
22. 22. Intravenous Patient-Controlled Analgesia Intravenous patient-controlled analgesia (PCA) optimizes delivery of analgesic opioids and minimizes the effects of pharmacokinetic and pharmacodynamic variability in individual patients. A PCA device can be programmed for several variables, including the demand (bolus) dose, lockout interval, and background infusion. 22
23. 23. A lockout interval that is too long may result in inadequate analgesia and decrease the effectiveness of intravenous PCA. Too short Lockout Interval-Repeated dosing- Undesirable side effect. most intervals range from 5 to 10 minutes, depending on the medication in the PCA pump. 23
24. 24. Intravenous patient controlled anaesthesia dose regimen 24
25. 25. Ketamine Traditionally recognized as an intraoperative anesthetic agent Its used for postoperative analgesia has increased because of its NMDA-antagonistic properties, which may be important in attenuating central sensitization and opioid tolerance. Perioperative ketamine reduced 24-hour PCA morphine consumption and postoperative nausea or vomiting and had minimal adverse effects. 25
26. 26. Regional Analgesic Techniques Neuraxial (primarily epidural) and peripheral regional analgesic techniques may be used for the effective treatment of postoperative pain. In general, the analgesia provided by epidural and peripheral techniques (particularly when local anesthetics are used) is superior to that with systemic opioids. use of these techniques may even reduce morbidity and mortality. 26
27. 27. Properties of neuraxial opoids 27
28. 28. Doses of neuraxial opoids 28
29. 29. Patient-Controlled Epidural Analgesia PCEA is a safe and effective technique for postoperative analgesia on routine surgical wards. Like intravenous PCA, PCEA allows individualization of postoperative analgesic requirements and may have several advantages over CEI. Background infusion in addition to the demand dose is more common with PCEA than with intravenous PCA . 29
30. 30. Patient-controlled Epidural Analgesia Regimens 30
31. 31. Peripheral Regional Analgesia Peripheral regional analgesic techniques as a single injection or continuous infusion can provide analgesia superior to that with systemic opioids. Wound infiltration and peripheral regional techniques (e.g., brachial plexus, lumbar plexus, femoral, sciatic- popliteal, and scalp nerve blocks) can be used to enhance postoperative analgesia. 31
32. 32. (2)Nausea & Vomiting Postoperative nausea and vomiting (PONV) are a common problem following general anesthesia, occurring in 2030% of all patients. Moreover, PONV may occur only at home within 24 hr of an uneventful discharge (postdischarge nausea and vomiting) in a significant number of additional patients. From a patients perspective PONV can be more problematic than postoperative pain. 32
33. 33. Risk factors for PONV Patients factor Anaesthetic techniques Young age Female gender Large body habitus History of prior PONV History of motion sickness General anaesthesia Opioids Volatile anesthetics 33
34. 34. Surgical factor Postoperative factor Strabismus surgery Laproscopic surgery Ear surgery Orchidopexy Gynaecological surgeries Tonsillectomy Postopertive pain Hypotension 34
35. 35. 35
36. 36. Commonly used antiemetic drugs 36
37. 37. (3)Delirium Approximately 10% of adult patients over the age of 50 who undergo elective surgery will experience some degree of postoperative delirium within the first 5 postoperative days. The most significant preoperative risk factors include advancing age (>70 years) preoperative cognitive impairment, decreased functional status alcohol abuse a previous history of delirium. 37
38. 38. Intraoperative factors that are predictive of postoperative delirium include 1.)surgical blood loss 2.) hematocrit less than 30% 3.)number of intraoperative blood transfusions. 38
39. 39. Management of delirium High risk patient should be identified before admission to PACU. Severely agitated patients require restraints or additional personnel to avoid self-inflicted injury. Elderly patients who are to undergo minor surgery should be scheduled in an outpatient center. It minimize the incidence of post op delirium. 39
40. 40. Emergence Excitement A transient confusional state that is associated with emergence from general anesthesia. Should be differentiated from persistent postoperative delirium. Common in children, with more than 30% experiencing agitation or delirium. Usually occurs within the first 10 minutes of recovery but can have onset later in children who are brought to the recovery room asleep. 40
41. 41. The peak age of emergence excitement in children is between 2 and 4 years. In children, emergence excitement is most frequently associated with rapid wake up from inhalational anesthesia. most often associated with sevoflurane and desflurane. 41
42. 42. Preventative measures are reducing preoperative anxiety, treating postoperative pain, and providing a stress-free environment for recovery. Medications that have been used to prevent and treat emergence agitation/delirium in children include midazolam, clonidine, dexmedetomidine, fentanyl, ketorolac, and physostigmine. 42
43. 43. (4)Shivering & Hypothermia Can occur due to intra op hypothermia or side effect of anaesthetic agents. Most important cause redistribution of heat core to peripheral compartment. Cool ambient temperature . Use of cold I.V fluids. Incidence related to duration of surgery and use of volatile anaesthetic agents. 43
44. 44. Management Forced air warming device. Exclude cause such as bacteremia , sepsis ,allergy or transfusion rxn. Meperidine (10-25 mg) also shown to reduce shivering. 44
45. 45. (5)Respiratory complications Most frequently encountered serious complications in the PACU. Majority are related to 1. airway obstruction 2. hypoventilation 3. hypoxemia. 45
46. 46. Upper Airway Obstruction Loss of Pharyngeal Muscle Tone Most frequent cause of airway obstruction in the immediate postoperative period. Characterized by a paradoxical breathing pattern. Can be relieved by jaw thrust maneuver or continuous positive airway pressure (CPAP) applied via facemask (or both). In selected patients, placement of an oral or nasal airway, laryngeal mask airway, or endotracheal tube may be required. 46
47. 47. Residual neuromuscular blockade Residual NM blockade is an important cause of airway obstruction in PACU. Pharyngeal function is not restored fully below a train of four ratio of 0.9 Clinically 5 second sustained head lift is a good indicator. (other signs grip strength, tongue protrusion, the ability to lift the legs off the bed) Ability to strongly appose incisor teeth against a tongue depressor is a best sign. This maneuver correlates with an average train-of-four ratio of 0.85 as opposed to 0.60 for the sustained head lift. 47
48. 48. Factors contributing to a prolonged NDMR block 48
49. 49. Factors contributing to prolonged DMR blockade 49
50. 50. Laryngospasm Sudden spasm of the vocal cords that completely occludes the laryngeal opening. Typically occurs in the transitional period when the extubated patient is emerging from general anesthesia. Patients who arrive in the PACU asleep after general anesthesia are also at risk for laryngospasm on awakening. 50
51. 51. Chest wall retraction High pitch inspiratory stridor Decreased breath sound Hypoxemia Jaw thrust with CPAP (up to 40 cm H2O) is often sufficient stimulation to break the laryngospasm. Skeletal muscle relaxation can be achieved with succinylcholine (0.1 to 1.0 mg/kg IV or 4 mg/kg IM). 51
52. 52. Edema or Hematoma Possible operative complication in patients undergoing prolonged procedures in the prone or Trendelenburg position. Surgical procedures on the tongue, pharynx, and neck, including thyroidectomy, carotid endarterectomy, and cervical spine procedures, can produce more localized tissue edema or hematoma. 52
53. 53. Evaluation of airway for tracheal extubation 1) After deflating the endotracheal tube cuff proximal end of the endotracheal tube is occluded . Patient is then asked to breathe around the tube. . Good air movement suggests that the patient's airway will remain patent after tracheal extubation. 2) measuring the intrathoracic pressure required to produce a leak around the endotracheal tube with the cuff deflated. 3)In volume controlled ventillation expiratory tidal volume can be calculated before and after cuff deflation. Patients who require reintubation generally have a smaller leak. 53
54. 54. Management Patients with airway obstruction should receive supplemental oxygen A combined jaw-thrust and head-tilt maneuver pulls the tongue forward and opens the airway. Insertion of an oral or nasal airway also often alleviates the problem. Any secretions or blood in the hypopharynx should be suctioned Postoperative wound hematomas following head and neck, thyroid, and carotid procedures can quickly compromise the airway; opening the wound immediately relieves tracheal compression. 54
55. 55. Mask-ventilation of a patient with severe upper airway obstruction resulting from edema or hematoma may be difficult Ready access to difficult airway equipments. Surgical backup for performance of an emergency tracheostomy. Dexamethasone (0.5 mg/kg)or aerosolized racemic epinephrine (0.5 mL of a 2.25% solution with 3 mL of normal saline) may be useful in some cases. 55
56. 56. Obstructive Sleep Apnea Obstructive sleep apnea syndrome is often an overlooked cause of airway obstruction in the PACU. Patients with OSA are particularly prone to airway obstruction and should not be extubated until they are fully awake and following commands. Continuous regional anesthesia techniques should be used to provide postoperative analgesia. In patient with OSA, plans should be made preoperatively to provide CPAP in the immediate postoperative period. 56
57. 57. Hypoxemia in PACU Mild hypoxemia is common in patients recovering from anesthesia unless supplemental oxygen is given during emergence. The routine use of a pulse oximeter in the PACU facilitates early detection. ABG measurements should be performed to confirm the diagnosis and guide therapy. Clinically- restlessness, tachycardia, or cardiac irritability (ventricular or atrial). Obtundation, bradycardia, hypotension, and cardiac arrest are late signs. 57
58. 58. Factors contributing to postop hypoxemia 58
59. 59. Alveolar Hypoventilation PaCO2 more than 45 mm of hg. Hypoventilation Significant hypoventilation clinically -PaCO2 is greater than 60 mm Hg or arterial blood pH is less than 7.25. Prolonged somnolence, airway obstruction, slow respiratory rate, tachypnea with shallow breathing, or labored breathing. Mild to moderate respiratory acidosis causes tachycardia and hypertension or cardiac irritability and even circulatory depression. 59
60. 60. Even a patient with a normal lungs may become hypoxemic if continue to hypoventilate while breathing room air. Management Arterial hypoxemia secondary to hypercapnia can be reversed by the administration of supplemental oxygen. External stimulation of the patient to wakefulness. Pharmacologic reversal of opioid or benzodiazepine effect or controlled mechanical ventilation of the patient's lungs. 60
61. 61. Pulmonary edema Pulmonary edema in the immediate postoperative period is often cardiogenic in nature secondary to intravascular volume overload or CHF. Less common cause includes postobstructive pulmonary edema , sepsis and TRALI. 61
62. 62. Postobstructive Pulmonary Edema Transudative edema produced by the exaggerated negative intrathoracic pressure generated by an inspiratory effort against a closed glottis. Muscular healthy patients are at increased risk of postobstructive pulmonay edema. Laryngospasm is the most common cause. 62
63. 63. Arterial hypoxemia is usually manifested within 90 minutes of the upper airway obstruction and is accompanied by bilateral fluffy infiltrates on the chest radiograph. Treatment is supportive and includes supplemental oxygen diuresis positive-pressure ventilation 63
64. 64. Supplemental Oxygen The choice of oxygen delivery system in the PACU is determined by the degree of hypoxemia, the surgical procedure, and patient compliance. Nasal cannula with bubble humidifier with flow of 6 L/min provides FIO2 of approximately 0.44. The other methods are through Hudson mask, Face tent oxygen or blow-by setups. 64
65. 65. Transfusion-Related Lung Injury Pulmonary edema in the PACU may include transfusion- related lung injury in any patient who received blood products intraoperatively. Typically manifested within 1 to 2 hours(maximum 6 hrs) after the transfusion of plasma-containing blood products. The resulting noncardiogenic pulmonary edema is often associated with fever and systemic hypotension. 65
66. 66. Diagnostic criteria for TRALI 66
67. 67. 67
68. 68. Management Treatment is supportive and includes supplemental oxygen and drug-induced diuresis. Mechanical ventilation may be needed to support hypoxemia and respiratory failure. Vasopressors may be required to treat refractory hypotension. 68
69. 69. Noninvansive ventilation An effective alternative to endotracheal intubation in the ICU setting. Noninvasive modes of ventilation in the PACU must be guided by careful consideration Contraindications hemodynamic instability life-threatening arrhythmias altered mental status, high risk of aspiration, inability to use nasal or facial mask (head and neck procedures) refractory hypoxemia 69
70. 70. Continuous Positive Airway Pressure 8% to 10% of patients who undergo abdominal surgery subsequently require intubation and mechanical ventilation in the PACU. The application of CPAP in this setting can decrease hypoxemia due to atelectasis by recruiting alveoli. Increases functional reserve capacity may also improve pulmonary compliance. Application of CPAP in the PACU significantly reduced the incidence of reintubation, pneumonia, respiratory faliure, and sepsis. 70
71. 71. (6)Hemodynamic Instability Hypertension Common in PACU and usually within 30 min of arrival. Patients with a history of essential hypertension are at greatest risk. Postoperative systemic hypertension and tachycardia are associated with an increased risk of unplanned critical care admission and a higher mortality . 71
72. 72. Factors leading to postoperative hypertension 72
73. 73. Management Mild hypertension generally does not require treatment Marked hypertension can precipitate postoperative bleeding, myocardial ischemia, heart failure, or intracranial hemorrhage. Any reversible cause should be identified and treated. Blood pressure greater than 2030% of the patient's normal baseline or those associated with adverse effects should be treated. 73
74. 74. Mild to moderate Hypertension should treated with -adrenergic blocker such as labetalol, esmolol, or propranolol; or calcium channel blocker or nitroglycerine patch. Severe Hypertension should be treated with intravenous infusion of nitroprusside, nitroglycerin, nicardipine, or fenoldopam . 74
75. 75. Hypovolemia Most common cause of the shock during perioperative period. 1. Ongoing third-space translocation of fluid 2. inadequate intraoperative fluid replacement 3. loss of sympathetic nervous system tone. 4. Ongoing bleeding should be ruled out. Patient should be managed with iv fluids, blood products and vasopressor if required. 75
76. 76. Causes of Systemic Hypotension 76
77. 77. Distributive (Decreased Afterload) Physiologic derangements, like iatrogenic sympathectomy, critical illness, allergic reactions, and sepsis. Neuromuscular blocking drugs are the most common cause of anaphylactic reactions in the operative setting followed by latex allergy Epinephrine is the drug of choice to treat hypotension secondary to an allergic reaction. If sepsis is suspected it is managed with fluid resuscitation , vasopressors and broad spectrum antibiotics. 77
78. 78. Cardiogenic (Intrinsic Pump Failure) Cardiogenic causes of include 1. myocardial ischemia and infarction 2. cardiomyopathy 3. cardiac tamponade 4. cardiac dysrhythmias. In low-risk patients (