Professional Documents
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UNIT (PACU)
Dr. Dwiana Sulistyanti, SpAN.,Mkes.,KAO
Color Oxygenation
Respiration
Can breathe deeply and cough Breathes deeply and coughs freely 2
Circulation
Blood pressure deviating > 50% from normal Blood pressure more than 50 mm Hg of normal 0
Consciousness
Activity
No movement Same 0
1Based on Aldrete JA, Kronlik D: A postanesthetic recovery score. Anesth Analg 1970;49:924 and Aldrete JA: The
post-anesthesia recovery score revisited. J Clin Anesth 1995;7:89.
2Ideally, the patient should be discharged when the total score is 10 but a minimum of 9 is required.
Table. Postanesthesia Discharge Scoring System (PADS).
Criteria Points
Vital signs
Within 20% of preoperative baseline 2
Within 2040% of preoperative baseline 1
> 40% of preoperative baseline 0
Activity level
Steady gait, no dizziness, at preoperative level 2
Requires assistance 1
Unable to ambulate 0
Nausea and vomiting
Minimal, treated with oral medication 2
Moderate, treated with parenteral medication 1
Continues after repeated medication 0
Pain: minimal or none, acceptable to patient, controlled with oral medication
Yes 2
No 1
Surgical bleeding
Minimal: no dressing change required 2
Moderate: up to two dressing changes 1
Severe: three or more dressing changes 0
1Based on Marshall SI, Chung F: Discharge criteria and complications after ambulatory surgery. Anesth Analg 1999;88:508.
2Score 9 is required for discharge
COMPLICATIONS
Cardiovascular Complications
Postoperative hypotension
A 20 to 30% decrease in BP from baseline
Differential diagnosis
Arterial hypoksemia
Hypovolemia
Spurious (cuff to wide, transducer not calibrated)
Pulmonary edema (excess fluid)
Myocardial ischemia
Cardiac dysrhythmias
SVR (regional blocks, drugs)
Pneumothorax
Cardiac tamponade.
Cardiovascular Complications
Postoperative hypotension
Treatment is determined by the mechanism
responsible for hypotension.
Oxygenation
Crystalloid solution (most appropriate): 300-500 mL iv over
15 minutes.
Transient improvement may indicate continual surgical bleeding
Absence of any improvement may reflect cardiac dysfunction
Vasopressors are temporizing measure to restore perfusion
pressure while the underlying cause for hypotension is
corrected
Cardiovascular Complications
Postoperative hypertension
A 20-30% increase in BP from baseline
Differential diagnosis
Arterial hypoxemia
Spurious (cuff too narrow, transducer not
calibrated)
Preexisting essential hypertension
Enhanced sympathetic nervous system activity
Excess fluid administration
hypothermia
Cardiovascular Complications
Postoperative hypertension
Treatment is determined by the mechanism
responsible for hypertension
Adequacy of oxygenation
Antihypertensive medications
Cardiovascular Complications
Cardiac dysrhytmias
Differential diagnosis
Asymptomatic ECG abnormalities
Bradycardia (increased PNS activity; heart block)
Tachycardia (increased SNS, paroxysmal atrial
tachycardia)
Premature contraction (atrial usually benign;
ventricular may be life-threatening.
Cardiovascular Complications
Cardiac dysrhytmias
Treatment is determined by the significance of
the cardiac dysrhytmias
Eliminate excessive PNS activity (atropine,
ephedrine)
Eliminate excessive SNS activity (analgesics, beta
antagonists)
Decreased ventricular irritability (lidocaine)
Artificial pace maker insertion vs administration of
isoproterenol
Respiratory Complications
Airway Obstruction
most commonly due to the tongue falling back
against the posterior pharynx
Other causes include laryngospasm; glottic
edema; secretions, vomitus, or blood in the
airway; or external pressure on the trachea
combined jaw-thrust and head-tilt maneuver
pulls the tongue forward and opens the airway
Insertion of an oral or nasal airway (nasal may
be better tolerated than oral)
Respiratory Complications
Hypoventilation
Differential diagnosis;
Inadequate ventilatory drive (residual effects of anesthetics; lack of sensory
stimulation)
Ventilatory mechanics
Increased airway resistance
Decreased compliance (obesity, fluid overload)
Residual neuromuscular blockade
Increased dead space (pumonary embolus)
Increased carbon dioxide production (hyperthermia, hyperalimentation)
TREATMENT;
should generally be directed at the underlying cause
Obtundation, circulatory depression, and severe acidosis (arterial blood pH <
7.15) are indications for endotracheal intubation
If naloxone is used to increase respiration, titration with small increments
(0.04 mg in adults)
Antagonism of opioid-induced depression with naloxone is a two-edged
sword
Respiratory Complications
Hypoxemia
Differential diagnosis
Distribution of ventilation ( mismatch of ventilation to perfusion)
Distribution of perfusion (mismatch of perfusion to ventilation)
Inadequate alveolar oxygen partial pressure
Decreased mixed venous oxygen partial pressure.
Treatment
Oxygen therapy with or without positive airway pressure
Oxygen concentration must be closely controlled in patients with chronic
CO2 retention
100% oxygen via a nonrebreathing mask or an endotracheal tube for
patients with severe or persistent hypoxemia.
Additional treatment should be directed at the underlying cause
Persistent hypoxemia in spite of 50% oxygen generally is an indication for
positive end-expiratory pressure (PEEP) or CPAP.
Bronchoscopy is often useful in reexpanding lobar atelectasis caused by
bronchial plugs or particulate aspiration. cause