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POST ANAESTHESIA POST ANAESTHESIA CARE UNIT (PACU)CARE UNIT (PACU)

DR.SHAILENDRA.V.L.DR.SHAILENDRA.V.L.

SPECIALIST IN ANAESTHESIASPECIALIST IN ANAESTHESIA..

AL BUKARIYA GENERAL HOSPITALAL BUKARIYA GENERAL HOSPITAL..

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Introduction Introduction

• Importance of PACU

• Adequate preparedness

• Sudden complication

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History of PACUHistory of PACU

• 1947: Anaesthesia Study Commission report

• Experience of trauma management in 2nd World War

• Advances in Surgery in 50’s and 60’s

• Day care surgery concept of the 90s

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Design of PACUDesign of PACU

• Location: – Close to Operating Rooms– Easy access to Lab, X-ray, Blood bank– Close to ICU

• Size:– Ideal 1.5 PACU bed for every OR– 120 square foot per patient– Minimum of 7 feet between beds

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Design of PACUDesign of PACU

• Facilities:– Fowler’s cot with side rails– Piped Oxygen, Vacuum and Air– Multiple electrical outlets– Large doors– Good lighting– Isolation for Immuno-compromised patients

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Equipments in PACUEquipments in PACU

• Tray with labeled Emergency drugs• Airway maintenance kit:

– Laryngoscope with all size blades– All sizes Endotracheal tubes– Face masks, Airways, Ambu Bag, Venturi

masks– Tracheostomy set– ICD set– Transport ventilator

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Equipments in PACUEquipments in PACU

• Personnel:– Requirement varies– 1 : 1 ratio good– 1 : 3 ratio acceptable for busy OR’s

• Monitors:– ECG– Pulse oximeter– Non invasive BP – EtCO2

– Invasive pressure monitor– Temperature

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Routine Post-Anaesthesia CareRoutine Post-Anaesthesia Care

• Criteria for shifting from OR---to---PACU– Conscious, awake, responds to simple

commands– Haemo dynamic stability– Clinical evaluation for NM blockade recovery– Maintainance of Oxygen Saturation– Normothermia

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Transportation to PACUTransportation to PACU

• Fowler’s cot with side rails

• Patient handed over to PACU nurse by the Anaesthesiologist

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Care in PACUCare in PACU

• Monitoring : ECG, SpO2, Blood pressure

• Oxygen therapy

• Pain therapy, anti-emetics

• Blood Pressure recording:– Every 5 minutes for 30 minutes– Every 15 minutes for next 30 minutes

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Post Operative ComplicationsPost Operative Complications

• Respiratory Complications:– Airway obstruction– Hypoxemia– Increased Left to Right shunt

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Post Operative ComplicationsPost Operative Complications

• Airway Obstruction:– Sagging tongue: Treated with triple maneuver

• Laryngeal Spasm:– Due to secretions– Due to irritable airways (smokers)

• Rx: 100% Oxygen through face mask• Hydrocoritsone 100 mg IV• If no improvement rapid intubation to secure the

airway

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Post operative ComplicationsPost operative Complications

• Hypoxemia:– Low FIO2:

• Diffusion hypoxemia (N2O 31 times more soluble than O2)

– Hypoventilation:• Inadequate N.M. blockade recovery• Respiratory depressant effect of volatile agents,

narcotics, benzodiazepines• Hypocarbia intra operatively• Upper abdominal incisions

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Post operative ComplicationsPost operative Complications

• Increased Right to Left Shunt:– Atelectasis:

Inadvertent endobroncial intubationAteclectasis of the lungIncreased Shunt ( R to L )Blockage of Brochus by blood or mucous plug

Pnemothorax: following rib injury following CVP placement

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Post operative ComplicationsPost operative Complications

• Circulatory Complications:– Hypotension:

• Decreased preload• Decreased myocardial contractility• Increased after load

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Post operative ComplicationsPost operative Complications• Decreased preload:

– Increased blood loss– Increased III space loss– Un diagnosed urinary loss– Septicemia

• Decreased myocardial contractility:– Depressant effect of GA drugs– Pre-existing ventricular dysfunction– Per operative Myocardial infarction

• Decreased After load:– Volatile agents depression– Septic shock– Profound decreased SVR

• Septic shock• Volatile agents effects

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Post operative ComplicationsPost operative Complications

• Hypertension:– Pain– Hypercapnia– Hypothermia– Hypoxemia– Excess Intra vascular volume– Pre-existing hypertension

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Post operative ComplicationsPost operative Complications

• Arrythmias:– Electrolyte imbalance ( K )– Hypoxia– Hypercarbia– Metabolic acidosis

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Post operative ComplicationsPost operative Complications

• Post-operative pain & agitation:– Ascertain adequacy of Blood-Gas exchange– Evaluate for any gastric or urinary distension– Rx: small doses of narcotics.

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Post operative ComplicationsPost operative Complications

• Nausea & Vomiting:– Frequently seen after

• lapraroscopic surgeries• Strabismus surgeries

Rx with Ondansetron 4mg IV adults / child 0.1mg/kg

Metoclopromide 0.15mg/kg IV

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Post operative ComplicationsPost operative Complications

• Hypothermia & shivering:– Air-conditioning : excessive cooling– Cold IV fluids transfused– Cold irrigating fluids used by the surgeon– Halothane anaesthesia

• Rx by warm blankets

• Warm IV fluids

• Inj. Pethidine 10mg IV

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Discharge criteria from PACUDischarge criteria from PACU

“ Neither an arbitrary time limit nor a discharge score can be used to define a medically appropriate length stay in the recovery room accurately ”

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Discharge criteria from PACU

• All patients must be evaluated by anesthesiologist prior to discharge from PACU

• Criteria for discharge developed by the Anesthesia department

• Criteria depends on where the patient is sent – ward, ICU, home

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Discharge criteria from PACU

1. Easy arousability

2. Full orientation

3. Ability to maintain & protect airway

4. Stable vital signs for at least 15 – 30 minutes

5. The ability to call for help if necessary

6. No obvious surgical complication (active bleeding)

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Post-anesthetic Aldrete recovery scorePost-anesthetic Aldrete recovery score

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Interpretation of Modified Aldrete’s Interpretation of Modified Aldrete’s scorescore

• Lowest score = 0 – 2• Score for patient to be shifted to next level of

care = 0 to 8– 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

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Post-anesthesia discharge scoring systemPost-anesthesia discharge scoring system

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Safe guidelines for discharging Safe guidelines for discharging home after ambulatory surgeryhome 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)

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