PACU Post-Anesthesia Care Unit
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Post anesthesia care unit management
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PACU Post-Anesthesia Care Unit
- 2. Postanesthesia Care Unit • The PACU is designed and staffed to monitor and care for patients who are recovering from the immediate physiologic effects of anesthesia and surgery resuscitate patients who are unstable provide a tranquil environment for the “recovery” and comfort of patients who are stable
- 3. PACU • Specially trained nurses skilled in the prompt recognition of postoperative complications make up the staff of the PACU • On arrival of a patient to the PACU, the anesthesiologist provides the PACU nurse with pertinent details of the patient’s history, medical condition, anesthesia, and surgery
- 4. PACU Oxygenation • pulse oximetry Ventilation • Resp Rate, airway patency, capnography Circulation • BP, HR, ECG Level of consciousness Temperature
- 5. PACU • Vital signs are recorded as often as necessary but at least every 15 minutes while the patient is in the unit.
- 6. Standards of PACU • All patients who have received general anesthesia, regional anesthesia or monitored anesthesia care shall receive appropriate postanesthesia management
- 7. Standards of PACU • 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
- 8. Standards of PACU • Upon arrival in the PACU, the patient shall be re- evaluated and a verbal report provided to the responsible PACU nurse by the member of the anesthesia care team who accompanies the patient.
- 9. Standards of PACU • 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.
- 10. Standards of PACU • A physician is responsible for the discharge of the patient from PACU • Multiple antiemetic agents are used for the prevention or treatment of postoperative nausea and vomiting (PONV). • Oxygen is administered for patients at risk of hypoxemia.
- 11. Standards of PACU • When available, forced air warmers should be used to reach the goal of normothermia. • Demerol or other opioid agonists should be used for the treatment of postoperative shivering but not replace treating hypothermia by rewarming.
- 12. Standards of PACU • Specific antagonists should be available whenever benzodiazepines, opioids, or neuromuscular blockers have been administered. • A mandatory minimum stay should not be required, but patients should be observed until they are no longer at risk for cardiopulmonary depression.
- 16. PACU “incidents”
- 20. PONV • Without prophylactic intervention, approximately one third of patients who undergo inhalational anesthesia will develop PONV (range, 10% to 80%) • From a patient’s perspective, PONV may be more uncomfortable than postoperative pain.
- 21. PONV delayed discharge from the PACU unanticipated hospital admission increased incidence of pulmonary aspiration significant postoperative discomfort
- 22. Antiemetic Drugs
- 23. Antiemetic Drugs
- 24. PONV • Although prophylactic measures to prevent PONV are more effective than rescue, a subset of patients will require treatment in the PACU even after appropriate prophylactic treatment.
- 25. PONV • If an adequate dose of antiemetic medication given at the appropriate time is ineffective, then simply giving more of the same class of drug in the PACU is unlikely to be of significant benefit.
- 27. Upper Airway Obstruction • Loss of pharyngeal muscle tone • Residual NM blockade • Laryngospasm • Airway edema/hematoma • Obstructive Sleep Apnea (OSA)
- 29. Upper Airway Obstruction • An obstructed upper airway requires immediate attention. • Efforts to open the airway by noninvasive measures should be attempted before reintubation.
- 30. Upper Airway Obstruction Jaw thrust +/-CPAP Oral/Nasal airway; LMA Tracheal intubation
- 31. Upper Airway Obstruction • The cause of the upper airway obstruction should be identified and treated • Sedating effects of opioids and benzodiazepines can be reversed with persistent stimulation or small, titrated doses of naloxone (0.3 to 0.5 μg/kg IV) or flumazenil (0.2 mg IV to maximum dose of 1 mg), respectively.
- 32. Upper Airway Obstruction • Residual effects of neuromuscular blocking drugs can be reversed pharmacologically or by correcting contributing factors such as hypothermia
- 34. Postop Hypoxemia • Right-to-left intrapulmonary shunt (atelectasis) • Mismatching of ventilation to perfusion (decreased functional residual capacity) • Congestive heart failure • Pulmonary edema (fluid overload, postobstructive edema) • Alveolar hypoventilation (residual effects of anesthetics and/or neuromuscular blocking drugs)
- 35. Postop Hypoxemia • Diffusion hypoxia (unlikely if receiving supplemental oxygen) • Inhalation of gastric contents (aspiration) • Pulmonary embolus • Pneumothorax • Increased oxygen consumption (shivering)
- 36. Postop Hypoxemia • Sepsis • Transfusion-related lung injury • Adult respiratory distress syndrome • Advanced age • Obesity
- 37. Pulmonary Edema • Pulmonary edema in the immediate postoperative period is often cardiogenic in nature – intravascular volume overload – congestive heart failure • Less frequently, pulmonary edema may result from airway obstruction (postobstructive pulmonary edema), sepsis, or transfusion
- 38. Pulmonary Edema
- 39. Postobstructive Pulmonary Edema forced inspiration against an obstructed airway large negative intrathoracic pressure increase in pulmonary vascular volume and pulmonary capillary transmural pressure risk of disruption of the alveolar–capillary membrane
- 40. Postobstructive Pulmonary Edema • Relief of the airway obstruction • Correction of hypoxemia • Addressing pulmonary edema
- 41. Postobstructive Pulmonary Edema • Persistent airway obstruction may necessitate an artificial airway, and acute respiratory failure would require artificial ventilation with oxygen and appropriate levels of PEEP. • A longer period of observation in PACU.
- 42. Postobstructive Pulmonary Edema • With prompt diagnosis and therapeutic action, NPPE resolves generally within 24 hr. • However, when recognition is delayed, patients with NPPE have mortality rates ranging from 11% to 40%. • A high index of suspicion - postextubation laryngospasm…..
- 50. MI in PACU • High risk patients • ST-segment and T-wave changes on the ECG • Determination of serum troponin levels • 12-lead ECG • Cardiology follow up
- 55. Postoperative shivering • Usually, but not always, associated with hypothermia • Accurate core body temperatures can be most easily obtained at the tympanic membrane
- 58. Delirium • Approximately 10% of patients older than 50 years of age who undergo elective surgery will experience some degree of postoperative delirium within the first 5 postoperative days
- 59. Delirium • Risk factors – Elderly (70 yrs or older) – Preop cognitive impairment – Decreased functional status – Alcohol abuse – H/o delirium
- 60. Emergence Excitement • Atransient confusional state that is associated with emergence from general anesthesia. • Emergence excitement is common in children, with more than 30% experiencing agitation or delirium at some period during their PACU stay.
- 61. Emergence Excitement • Usually occurs within the first 10 minutes of recovery • Typically resolves quickly and is followed by an uneventful recovery • In children, emergence excitement is most frequently associated with rapid “wake up” from inhalational anesthesia.