ASA PRACTICAL GUIDELINES FOR POSTANESTHETIC CARE

2013

SUPARNO ADI SANTIKA

A Review Article

POSTANESTHESIA CARE

• Definition : Activities undertaken to manage the patient after completion of a surgical procedure and the concormitant primary anesthetic

• Purpose : Improved post-anesthetic care

outcome

POSTANESTHESIA CARE

• Initial emergence • Transport to the PACU• Management of PACU problems• Continuous care of complications resulting

from anesthesia• Subsequent assessment (postoperative visit)

POSTANESTHESIA CARE

• Focus : – Reducing post operative adverse effect– Providing uniform assessment of recovery,

monitoring and management patient safety– Improving post anesthetic quality of life– Streamlining post operative care and

discharge criteria

ASA POSTANESTHESIA CARE ASSESSMENT AND

MONITORING• Respiratory Function :

– Early detection of hypoxemia (Level A2-B evidence)

– Periodic assessment and monitoring airway patency, respiratory rate and Oxygen saturation (SpO2)

ASA POSTANESTHESIA CARE ASSESSMENT AND

MONITORING• Cardiovascular Function :

– Pulse, Blood pressure, ECG monitoring Perioperative complication

– Certain catagories ECG may not be necessary • Young adult w/o cardiac event• etc

ASA POSTANESTHESIA CARE ASSESSMENT AND

MONITORING• Neuromuscular Function :

– Neuromuscular blockade monitoring (B2-B evidence)

• Mental Status– POCD (Geriatric patient)

ASA POSTANESTHESIA CARE ASSESSMENT AND

MONITORING• Temperature :

– Fever Postoperative Complication– Shivering Postoperative Complication

• Pain :– Pain Controlled

ASA POSTANESTHESIA CARE ASSESSMENT AND

MONITORING• Nausea and Vomitting :

– PONV

• Fluid :– Assess hydration status and px fluid

management

ASA POSTANESTHESIA CARE ASSESSMENT AND

MONITORING• Urine output and Voiding :

– Identifying px w/ urine retention (B3-B evidence)

– Evaluation of px fluid management

• Drainage and Bleeding:– Assess and consider blood component

replacement therapy

PROPHYLAXIS and TREATMENT NAUSEA AND VOMITING

• Antihistamine : Promethazine (A3-B evidence)• 5-H3 Antiemetics : Rescue antiemetics and

Reduce vomiting (Ondansentron, Tropisentron), Reduce vomiting (Granisentron, Dolasentron). Newest (Palonosentron, Ramosentron A2-B evidence)

• Tranquillizer : Inapsine (Droperidol), Haloperidol (rescue antiemetics) .. Hydroxizine, Perphenazine (Vomiting, dizziness, anxiety, headache)

• Metoclopramide• Scopolamine

• Administration of Suplemental Oxygen :– Prevent Hypoxia during px transportation– Prevent Hypoxia in recovery room(A3-B Evidence)

Treatment during Emergence and Recovery

• Normalizing Patient Temperature :– The perioperative maintenance of

normothermia and – The use of forced-air warming reduce

shivering and – Improve patient comfort and satisfaction.– Pharmacology agent for reduce shivering :

• Meperidine (Agonist Opioid)

Treatment during Emergence and Recovery

• Benzodiazepines : Flumazenil (A3-B evidence) reduce time to emerge after sedation Nausea, BP instability, agitation-restless, dizziness, resedation-drowsiness

Antagonism of the Effects of Sedatives, Analgesics,and Neuromuscular

Blocking Agents

• Opioids : Naloxon (A3-B evidence) reduce time to emerge and recovery of spontaneous respiration after GA Not for routine use

Antagonism of the Effects of Sedatives, Analgesics,and Neuromuscular

Blocking Agents

• Urinate before discharge : - benefits ex ODC

• Drink clear fluid before discharge : Vomit• Responsible individual to accompany them

home after discharge : agree• Minimum mandatory stay in recovery

Discharge Protocol

Practical Appraisal

COMMON COMPLICATIONS POSTANESTHESIA

• Nausea/vomiting 5%• Unexpected alterations in mental state 5%• Requirement for upper airway support 3.6%• Hypotension 3%• Dysrhythmias 2%• Hypertension, myocardial ischemia, or a

major cardiovascular complication <1%

Checklist for Evaluating Patients Before Departing the OR and After Arriving in the PACU

• Airway patency• Breathing (rate and depth)• Arterial oxygenation (pulse oximeter)• Blood pressure• Heart rate, ECG• Level of SAB or EPIDURAL• Level of consciousness

CARE IN THE PACU• Admitting the Patient to the PACU

– Supplemental oxygen– Monitoring devices

• Pulse oximeter• ECG• Temperature • BP

– Routine evaluation– Anesthesiologist provides complete report– Anesthesiologist leaves only when satisfied that

patient can be cared for by the receiving personnel

REPORT ON ADMITTING A PATIENT TO THE PACU

• Patient’s name

• Brief medical history– Significant comorbidities (asthma, angina)– Drugs – Allergies

• Surgery – Site– bleeding

• Anesthetic– Anesthetic agents, sedatives, narcotics– State of alertness– Muscle relaxants, recovery– Expected vital signs

• Summary of fluid balance– Blood and fluids given– Urine output– Blood loss

• Expected problems and plans– Oxygen required– Fluid therapy– Pain management– Any alterations in usual PACU

discharge criteria

COMMON PROBLEMS

IN THE PACU

DELAYED AWAKENING• Acute metabolic disorders

– Hypoxia – Hypercarbia– Hypoglycemia– Other electrolyte disorders– Water intoxication

• Residual neuromuscular blockade

• CNS disorders– Stroke– Post-anoxic encephalopathy

• Residual effects of anesthetics, sedatives

• Other medications– Premedicants– Central anticholinergic syndrome:

scopolamine, atropine– Illicit drugs– Cimetidine

• Hypothermia

• Preexisting coma or obtundation

• Interpatient viariation in response to anesthetics

AGITATION AND DELIRIUM

• Hypoxemia or airway obstruction

• Hypercarbia • Cerebral ischemia• Pain• Full bladder• Incomplete reversal of

neuromuscular blockade• Withdrawal from alcohol or

other drugs

• Central anticholinergic syndrome (scopolamine, atropine, tricyclic antidepressants, antihistamines, butyrophenones or phenothiazines)

• Residual anesthetics or sedatives (barbiturates, ketamine)

• Senile dementia• Emotional or anxious state prior to

anesthesia• Patients who awaken restrained

(e.g. casts)

PAIN• Operative site• Muscle spasm• Bladder distension• Musculoskeletal

» Exacerbation of arthritis» Injury from positioning

• Tight cast or dressing• Phlebitis, infiltration of IVF• Angina• Corneal abrasion

NAUSEA AND VOMITING• History of nausea or

vomiting after previous operations

• Gastric distension– Ileus– Bowel obstruction– Prolonged or inept mask

ventilation

• Full stomach before surgery

• Opioids

• Type of surgery– Ophthalmologic

procedures– Laparoscopy– Otorhinologic procedures

especially inner ear– Abdominal operations

RESIDUAL NMB

• Any patient with unexplained upper airway obstruction, hypoventilation, or delayed awakening after a general anesthetic should be evaluated for residual neuromuscular blockade.

• Head or leg lift test for 5 seconds

• Treatment additional neostigmine

AIRWAY OBSTRUCTION

• Causes – Somnolence– Residual weakness– Obtunded airway reflexes– Upper airway edema– Sleep apnea– Obesity– Partial airway obstruction preoperatively

• Signs – Noisy breathing– Dyspnea– Cyanosis– Hypoxemia– CV abnormalities– Tracheal tug– Nasal flaring– Rocking motions of the chest

• Treatment– Repositioning the head and

neck– Oxygenation– Jaw thrust– Nasal and oral airways– Tracheal intubation

HYPOXEMIA

• Atelectasis• Aspiration pneumonitis• Decreased FRC• Pulmonary edema• Pneumothorax• Pneumonia• Splinting from incisional

pain

• Increased oxygen consumption (fever, shivering)

• Decreased cardiac output• Depression of ventilatory

responses to hypoxemia by residual anesthetics

• Depression of ventilatory responses to hypercarbia by opioids

RESPIRATORY DEPRESSION

• Causes – Residual drug effects– Airway obstruction– Lung disease (COPD)– Increased CO2

production (shivering, fever)

– Opioids

• Treatment – Oxygenation– Stimulation– Assisted or controlled

PPV– Naloxone (40-80mg) if

due to opioids

HYPERTENSION/HYPOTENSION

• Hypertension– Preexisting HTN– Anti-HTN medication not

taken– Pain– Distended bladder– Volume overload– Emergence delirium– Hypoxemia, hypercarbia– Hypothermia with

vasoconstriction

• Hypotension– Hypovolemia due to

unreplaced intraoperative losses, continuing bleeding and third space losses

– Residual effects of SAB or epidural anesthesia by blunting sympathetic responses

– Occult hypovolemia after opioids

– LVF– Sepsis– Pulmonary embolus– Tension pneumothorax

HYPOTHERMIA

• Effects– Slows emergence– Impairs organ function

and coagulation– Exacerbates HTN– Increases oxygen

consumption and demands in cardiac output

• Management– Warm the OR to 26C– Use warming blankets

or active heating devices

– Warm IVFs

FEVER

• Less common than hypothermia• Common case: pulmonary atelectasis • Less common: febrile reactions to drugs

and transfused blood• Rare but grave: onset of MH

ASA SUMMARY TREATMENT RECOMMENDATIONS

• Nausea and vomiting– Antihistamines, 5-HT3 antagonists,

droperidol, dexamethasone, scopolamine or metoclopramide.

• Supplemental oxygen for patients at risk of hypoxemia.

• Fluids– Postoperative fluids should be

managed in the PACU.– Certain procedures may require

additional fluid management.• Temperature

– Normothermia should be maintained.– Forced-air warming systems are most

effective for treating hypothermia.– Pharmacologic agents for the reduction

of shivering• Meperidine is recommended.

• Antagonism of the effects of sedatives, analgesics, and NMB

– Antagonism of benzodiazepines• Antagonists should be available.• Flumazenil should not be used routinely. • Flumazenil may be administered to

antagonize respiratorydepression and sedation.

– Antagonism of opioids• Antagonists (e.g., naloxone) should be

available but should not be used routinely. Naloxone may be administered to antagonize respiratorydepression and sedation.

– Reversal of neuromuscular blockade• Specific antagonists should be

administered for reversal ofresidual neuromuscular blockade as indicated.

After reversal, patients should be observed to ensure that cardiorespiratory depression does not occured.

ROUTINE DISCHARGE CRITERIA FROM PACU

• Vital signs satisfactory and stable• Return to postoperative mental state• Adequate pain control• Immediate treatment of any complications• Adequate treatment of nausea/vomiting• Adequate function of all drains, tubes, catheters• Surgical bleeding controlled or treated• Postoperative orders reviewed and implemented• Laboratory studies needed immediately obtained and

results reviewed

ASA SUMMARY OF RECOVERY AND DISCHARGE CRITERIA

GENERAL PRINCIPLES• Medical supervision of recovery and discharge is the responsibility of the supervising practitioner.• The PACU should be equipped with appropriate monitoring and resuscitation equipment.• Patients should be monitored until appropriate discharge criteria are satisfied.• Level of consciousness, vital signs, and oxygenation (when indicated) should be recorded at

regular intervals.• A nurse or other individual trained to monitor patients and recognize complications should be in

attendance until discharge criteria are fulfilled.• An individual capable of managing complications should be immediately available until discharge

criteria are fulfilled.

GUIDELINES FOR DISCHARGE• Patients should be alert and oriented. Patients whose mental status was initially abnormal should

have returned to their baseline.• Vital signs should be stable and within acceptable limits.• Discharge should occur after patients have met specified criteria. Use of scoring systems may

assist in documentation of fitness for discharge.• Outpatients should be discharged to a responsible adult who will accompany them home and be

able to report any postprocedure complications.• Outpatients should be provided with written instructions regarding post procedure diet,

medications, activities, and a phone number to be called in case of emergency.

ALDRETE SCORING SYSTEM

ELEMENTS OF POSTANESTHETIC VISIT

• Overall patient satisfaction. Did the perioperative course match expectations? What should be done differently next time?

• What does the patient remember about the induction or about being in the OR? This may reveal intraoperative awareness.

• Adequacy of pain relief.

• Review outcome of any special problem such as nausea and vomiting, HTN, back pain.

•Objectives–Alerts anesthesiologist to complications that can be treated such as PDPH, dental injuries, backache, intraoperative awareness

–Improvement of care

–Corrects misconceptions/misunderstandings that might lead to dissatisfaction/litigation

TREATMENT OPTIONS IN RELATION TO MAGNITUDE OF POSTOPERATIVE PAIN EXPECTED AFTER SURGERY

FACTORS INFLUENCING ANALGESIC REQUIREMENTS

• Age: elderly patients request smaller doses. • Sex. • Pre-operative analgesic use. • Past history of poor pain management. • Coexisting medical conditions such as substance abuse or

withdrawal, hyperthyroidism, anxiety disorder, affective disorder, hepatic or renal impairments.

• Cultural factors and personality. (e.g., patients vary from being intolerant of any discomfort to surprising self-control or patients consider pain to be a normal part of life).

• Preoperative patient education (can improve expectations, compliance and ability to effectively interact with pain management techniques).

• Site of operation: thoracic and upper abdominal operations are associated with the most severe pain.

• Individual variation in response and pain threshold. • Attitude of the ward staff.

For all the happiness mankind can gain,

It is not in pleasure, but in rest from pain.

John Dryden (1631-1700)