Post AnAesthesia Care

1. Post AnAesthesiaCare By : Dr. NurAizaIdris Moderator : Dr. MohdRozi

2. Outline • Post AnaesthesiaCare Unit • Post Operative Complication

3. Post AnaesthesiaCare Unit • Definition • Staffing • Design • Equipment • Monitoring • Admission Report

4. Recovery Room

5. Definition • Activities undertaken to safely manage the patient following a surgical procedure, including identification and immediate treatment of early complications of both anaesthesia and surgery before they develop into life-threatening consequences (reference : Quality and safety guidelines of postanaesthesia care – European Society of anaesthesiology) • Activities included • Monitoring • Identification of post-op complication • Treatment of complication • So this is the role of the PACU (post anest care unit). Their purpose is to improve postanaesthesia care outcomes for patients who have just had anaesthesia

6. Functions of PACU • Immediate postoperative treatment in the PACU, • Preoperative optimization of severely ill patients’ conditions in special situations • Titration and optimization of acute pain therapy • Buffer before intensive care unit (ICU), high dependency unit (HDU) or ward admission • Evaluation and determination of further treatment on ICU, HDU or ward • Improve or optimize patient’s condition for further treatment at ICU, HDU or ward.

7. Functions of PACU • These functions are supervised by the anesthesiologist and the surgeon. • PACU is run by the anesthesiologists and the surgeon who operate on the patient will be called if any complication occurs related to the surgical procedure.

8. Staffing • Nurses specifically trained in the care of patients emerging from anaesthesia • Expert in : 1. airway management 2. advanced cardiac life support 3. problem with surgical patient e.g wound care, drainage catheters, bleeding • Ratio of 1 recovery nurse for 2 patients • Under medical direction of anaesthesiologist • reflect coordinated effort between anaesthetist, surgeon & consultants • anaesthesiologist manage the analgesia, airways, cardiac, pulmonary and metabolic problems • surgeon manage any problem related to surgical procedures

9. Design • Location: • should be locate near the OR. • A central location that the pt. can be rush back to surgery with easy and full access. • Capacity: • Average, 1.5 -2 patients for each operating table, less if long-lasting procedures are dominant with slower patient turn over or more if short procedures or day case surgery. • Construction guidelines : minimum of 7 ft between beds and 120 sq ft per patient • Each patient space should be well lighted and large enough (12–15 m2 per bed as a minimum) to allow easy access to patients in spite of poles for equipments.

10. Average PACU stay is1-2hours, not more than 24 hours. • Open ward design - to facilitate observation of all patients simultaneously • Equipped with multiple electrical outlet, oxygen, air, suction at each space

11. Equipments and Facilities • Bedside monitoring devices – pulse oxymeter – ECG – noninvasive blood pressure (BP) monitor • Immediately available monitoring devices – ECG recording, – capnograph, - Nerve stimulator – means of measuring temperature. • Specific additional monitoring (e.g. vascular or intracranial pressures, cardiac output or some biochemical variables): – may be required and should be performed on a case-by-case basis for selected patients or selected procedures.

12. Equipments and Facilities • Central monitor station – It controls and records all warnings and alarms of bedside monitors and provides documentation in the form of hard copies, and is therefore recommended. • Facilities needed – defibrillator and resuscitation trolley appropriately supplied, – difficult airway devices, – immediate access to blood gas analysis and acute laboratory testing, – access to mobile radiograph and ultrasound imaging and endoscopies, – warming blankets, – forced air-warming devices for each bed, – sufficient air condition system providing a minimum of 15 air change rate per hour for sufficient scavenging of anaesthesia gases and other disinfectant vapours.

13. Airway maintenance kit: • Laryngoscope with all size blades • All sizes Endotracheal tubes • Face masks, Airways, Ambu Bag • Tracheostomy set • ICD set ( Intercostal drain) • Transport ventilator

14. Transfer of Patient (OR to PACU) • By suitably trained staff, under the supervision of an anaesthetist, • Portable monitoring is recommended if alteration or deterioration of patient’s condition may be anticipated or the distance of operating room and PACU makes it reasonable, • Steps should be taken to protect the patient during transfer mainly from: – traumatic injury, – hypoxia, – hypothermia, – accidental disconnections or removal of drains, lines, and catheters.

15. Properly designed transfer trolleys or beds are needed, equipped with: – oxygen cylinders, masks, and tubing, – infusion poles, – equipment(s) to secure and support airway and assist ventilation; – provision of clamps for drainage tubes, – protective ‘sides’, – a means to produce head-down tilt.

16. Transfer of Patient (OR to PACU) • Handover: on arrival to the receiving unit • full and formal handover should take place from professional to professional • with a completed anaesthetic record and important details of surgical procedure • with specific verbal and written instructions for postoperative care, • drugs and fluid regimens must be written on appropriate charts, • the anaesthetist should ensure that recovery staff is taking over the responsibility before leaving the patient. • Observation and record keeping • It is important for the patient to be continuously monitored during the transfer.

17. Admission Report • Preoperative history • Intra-operative factors: • Procedure • Type of anesthesia • EBL (Estimated Blood Loss) • UO(Urinary Output) • Assessment and report of current status • Post-operative instructions

18. Monitoring • All the patients transferred to the PACU should be monitored • Respiratory functions (O2 sat, capnography) • Cardiovascular stability (pulse, BP, ECG) • Neuromuscular function (espc those received neuromusc block agent) • Mental status • Temperature • Pain • Nausea and vomiting • Fluid and hydration • Urine output • Drainage and bleeding

19. Discharge • Duration • minimum length of stay (usually around 30mins) • Patients receiving regional anesthesia should show signs of resolution of both sensory and motor blockade prior to discharge.

20. majority of patients can meet discharge criteria within 60 minutes in the PACU • patients with RA - show signs of resolution of both sensory and motor blockade - to avoid inadvertent injuries due to motor weakness or sensory deficits

22. Standards for Post Anest Careapproved by ASA, 2009 • All patients who have received general, regional or monitored anesthesia care shall receive appropiatepostanesthesia management • 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 appropiate to the patient's condition. • 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 • The patient's condition shall be evaluated continually in the PACU • A physician is responsible for the discharge of the patient from the PACU

23. Recovery Room Complications

24. COMPLICATIONS • Respiratory complications a. Airway obstruction b. Hypoventilation c. Hypoxemia • Circulatory complications a. Hypotension b. Hyertension c. Arhythmias

25. Complications • Agitation • Failure to regain consciousness • Postoperative pain • Nausea & vomiting • Shivering & hypothermia

26. RESPIRATORY COMPLICATIONS • Most frequently encountered in PACU AIRWAY OBSTRUCTION • Partial obstruction -sonorous respiration • Total obstruction - cessation of airflow, absence breath sounds, paradoxic chest movement ( chest descends as the abdomen rises ) • Causes : a. Tongue falling back ( most common) b. Laryngospasm c. Glottic edema d. Secretions e. Vomitus / blood f. External pressure on the trachea (neck hematoma)

27. Management..1. Tongue fall back - Combined jaw-thrust and head- tiltmaneuver pulls the tongue forward and opens the airway - Insertion of oral or nasal airways - nasal airways better tolerable during emergence and lessen the likelihood of trauma to the teeth when patient bites down

28. Laryngospasm • characterized by high-pitched crowing noises; maybe silent with complete glottic closure • Spasm of vocal cord following airway trauma, repeated instrumentation, or stimulation from secretions or blood in the airway Management.. • Jaw-thrust maneuver + positive airway pressure via tight-fitting face mask • Insertion of oral or nasal airway - to ensure patent airway till vocal cord • Suction for any secretions or blood - to prevent recurrence

29. REFRACTORY LARYNGOSPASM - treated aggresively with a small dose of succinylcholine (10-20mg) and temporary positive pressure ventilation with 100% oxygen ( to prevent hypoxaemia) - Intubation ( occasionally necessary) - Cricothyrotomy or transtracheal jet ventilation ( if intubation unsuccesful)

30. 3. Glottic edema • an important cause of airway obstruction in infants and young children Management… • IV dexamethasone 0.5mg/kg • Aerosolized racemic epinephrine • Adults: 0.5–0.75 ml of a 2.25% solution in 2.0 ml normal saline. • Pediatrics: 0.25–0.75 ml of a 2.25% solution in 2.0 ml normal saline

31. 4. External pressure on trachea • Postoperativewound hematomas following head and neck, thyroid surgery can quickly compromise the airway Mx .. • open the wound immediately relieves tracheal compression

32. HYPOVENTILATION • Definition : PaCo2 greater than 45mmHg • Mild, and many cases are overlooked • Significant hypoventilation PaCo2 > 60mmHg arterial blood pH < 7.25 Clinical signs : • excessive or prolonged somnolence • airway obstruction • slow respiratory rate • tachypnea with shallow breathing • Or, laboured breathing • Mild to moderate acidosis - tachycardia, hypertension or cardiac irritability • Severe acidosis - circulatory depression

33. Hypoventilation ( cont.) causes : • residual depressant effect of anaesthetic agent on respiratory drive • opiod –induced • Excessive sedation • Inadequate reversal • Metabolic factors ( e.ghpokalemia or resp acidosis) • Splinting due to incisional pain and diphragmatic dysfunction following upper abdominal or thoracic surgery, abd distension • shivering, hyperthermia, or sepsis - increase CO2 production

34. Management.. • Treat underlying cause • Intubation ( marked hypoventilation, obtundation, severe acidosis,circulatory depression) • IV naloxone (0.04mg increments) or… • IV doxapram (60-100mg , followed by 1-2mg/min) - does not reversed analgesia, but can cause hypertension & tachycardia • Cholinesterase inhibitor - for residual paralysis Prevention.. - judicious opiod analgesia, epidural or intercostal nerve block for upper abdominal or thoracic procedures

35. HYPOXEMIA • Mild hypoxemia is common in patients recovering from anesthesia • Mild to moderate hypoxemia (PaO2 50-60mmHg) in young healthy patients may be well tolerated initially • but.. With increasing duration or severity there is progressive acidosis and circulatory depression

36. Causes • Hypoventilation • Increased right- to- left intrapulmonary shunting ( most common cause) • Diffusion hypoxia • Decreased cardiac output • Increased oxygen consumption (shivering)

37. Increased intrapulmonary shuntingfrom a decreased FRC relative to closing capacity is the most common cause of hypoxemia following general anesthesia • upper abdominal & thoracic surgery - greater reduction in FRC • semi-upright position maintain FRC

38. management • Oxygen therapy - 30-60% oxygen - higher concentration in patients with underlying pulmonary or cardiac disease - guided by SPO2 or ABG • Intubation - pt with severe or persistent hypoxemia • Treat underlying cause

39. CIRCULATORY COMPLICATIONS • Hypotension • usually due to decreased venous return, left ventricular dysfunction,excessive arterial vasodilatation

40. Causes.. • Hypovolemia • Hypothermia - venoconstriction • Spinal or epidural anesthesia - relative hypovolemia • Sepsis • Allergic reactions • Tension pneumothorax • Cardiac tamponade • Coronary artery or valvular heart disease

41. Management… • Mild hypotension during recovery from anesthesia is common - reflects decrease in sympathetic tone , associated with sleep or residual effect of anesthetic agents (not require treatment) • Significant hypotension - reduction of BP 20-30% below baseline (require treatment) • Fluids • vasopressor or inotrope • If pneumothorax - insert chest tube • cardiac tamponade - pericardiocentesis or thoracotomy

42. 2. Hypertension • Postoperative hypertension is common within the first 30 mins in PACU - noxious stimulation from incisional pain, intubation or bladder distension • Reflect sympathetic activation - neuroendocrine response to surgery • Secondary to hypoxemia, hypercapnia,met acidosis • Systemic hypertension • Fluid overload

43. Management • Mild hypertension – not require treament • Marked hypertension - treat individualized • Beta blocker ( labetolol, esmolol, propanolol) • Calcium channel blocker • Hydralazine Marked hypertension in patients with limited cardiac reserve requires direct intra-arterial pressure monitoring

44. 3. Arrythmia • Residual effects from anesthetic agent, increased sympathetic nervous system activity, metabolic abnormalities, preexisting cardiac or pulmonary disease predispose to arrhytmia • Bradycardia - residual effects of neostigmine or beta adrenergic blocker • Tachycardia - effect of anticholinergic agent, vagolytic drug, beta agonist - pain - fever - hypovolemia - anemia

45. POSTOPERATIVE PAIN • Asses the patient to determine the cause of the pain. • Pain may be related to non-surgical causes • - full bladder • - caffeine withdrawal • Hypothermia • Hypoxia

46. Moderate to severe pain can be managed by parenteral opiods, RA or nerve blocks. • Adequate analgesia must be balanced against excessive sedation • Analgesic effect : peak within 4-5mins • Pt fully awake - PCA • IM opioid - delayed and variable onset ( 10-20min) - delayed resp depression ( up to 1 H)

47. SHIVERING AND HYPOTHERMIA • Shivering can occur as a result of : - intraoperative hypothermia - effects of anesthetic agents • Most important cause of hypothermia is a redistribution of heat from the body core to the peripheral compartments

48. Other contributary factors are : • cold ambient temperature in OR • prolonged exposure of a large wound • use of unwarmed intravenous fluids • high flows of unhumidified gases

49. Shivering • common during or after emergence from GA • represents the body’s effort to increase heat production and raise body temperature • associated with intense vasoconstriction • part of nonspecific neurologic signs (posturing, clonus, or babinsk’i sign) • related to duration of surgery and use of high concentration of volatile anesthetic • Not all patients who shiver postoperatively are hypothermic, thus suggesting that mechanism of this event may be related to inadequate descending control of spinal reflexes after inhalation anesthesia.

50. Treatment • forced-air warming device • warming lights • heating blanket • IV Meperedine 25 – 30mg intravenusly