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 Patients 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.
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 respiratory depression and sedation. Antagonism of opioids Antagonists (e.g., naloxone) should be available but should not be used routinely. Naloxone may be administered to antagonize respiratory depression and sedation. Reversal of neuromuscular blockade Specific antagonists should be administered for reversal of residual 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)