بسم الله الرحمن الرحيم

1. بسم الله الرحمن الرحيم

2. Postoperative care- Post Anesthesia Care Unit“PACU”

3. PACU • Design should match function • Location: • Close to the operating suite. • Access to x-ray, blood bank & clinical labs. • Monitoring equipment • Emergency equipment • Personnel

4. Admission to PACU • Coordinate prior to arrival, • Assess airway, • Administer oxygen, • Apply monitors, • Obtain vital signs, • Receive report from anesthesia personnel.

5. PACU - ASA Standards • Standard I All patients should receive appropriate care • Standard II All patients will be accompanied by one of anesthesia team • Standard III The patient will be reevaluated & report given to the nurse • Standard IV The patient shall be continually monitored in the PACU • Standard V A physician will signing for the patient out of the PACU

6. Patient Care in the PACU • Admission • Apply oxygen and monitor • Receive report • Monitor & Observe & Manage  To Achieve • Cardiovascular stability • Respiratory stability • Pain control • Discharge from PACU

7. Monitoring in the PACU • Baseline vital signs. • Respiration • RR/min, Rythm • Pulse oximetry • Circulation • PR/min & Blood pressure • ECG • Level of consciousness • Pain scores

8. Initial Assessment • Color • Respiration • Circulation • Consciousness • Activity

9. Aldrete Score

10. Common PACU Problems • Bleeding • Agitation • Delayed recovery • “PONV” • Pain • Oliguria • Airway obstruction • Hypoxemia • Hypoventilation • Hypotension • Hypertension • Cardiac dysrhythmias • Hypothermia

11. Airway Obstruction • Most common tongue in posterior pharynx • May be foreign body • Inadequate relaxant reversal • Residual anesthesia

12. Management of Airway Obstruction • Patient’s stimulation, • Suction, • Oral Airway, • Nasal Airway, • Others: • Tracheal intubation • Cricothyroidotomy • Tracheotomy

13. Hypoventilation • Residual anesthesia • Narcotics • Inhalation agent • Residual Relaxant • Post oper - Analgesia • Intravenous • Epidural

14. Hypoventilation Treatment • Close observation, • Assess the problem, • Treatment of the cause: • Reverse relaxant • Reverse narcotic • Reverse midazolam

15. Hypertension • Common causes: e.g. • Pain • Full Bladder • Hypertensive patients • Fluid overload • Excessive use of vasopressors

16. Hypertension Treatment • Effective pain control • Sedation • Anti-hypertensives: • Beta blockers • Alpha blockers • Hydralazine (Apresoline) • Calcium channel blockers

17. Hypotension • Decreased venous return • Hypovolemia, •  fluid intake •  losses • Bleeding • Sympathectomy, • 3rd space loss, • Left ventricular dysfunction

18. Treatment of Hypotension • Initially treat with fluid bolus, • + Vasopressors, • + Correction of the cause

19. Dysrhythmias • Secondary to • hypoxemia • hypercarbia • Acidosis • Catecholamines • Electrolyte abnormalities • Hypothermia

20. Dysrhythmia Treatment • Identify and treat the cause, • Assure oxygenation, • Pharmacological

21. Urine Output • Oliguria • Hypovolemia, • Surgical trauma, • Impaired renal function, • Mechanical blocking of catheter. • Treatment: • Assess catheter patency • Fluid bolus • Diuretics e.g. Lasix

22. Post op Bleeding Causes: • Usually surgical problem • Coagulopathy Treatment: • Start i.v. lines  push fluids • Blood sample, • Cross matching, CBC, • Coagulopathy • Notify the surgeon, • Correction of the cause

23. Hypothermia • Most of patients will arrive cold • Treatment: • Get baseline temperature • Actively rewarm • Administer oxygen if shivering • Take care for: • Pediatric, • Geriatric.

24. Altered Mental Status • Reaction to drugs? • Drugs e.g. sedatives, anticholinergics • Intoxication / Drug abusers • Pain • Full bladder • Hypoventilation • Low COP • CVA

25. Treatment of Altered Mental Status • Reassurances, • Always protect the patient, • Evaluate the cause, • Treatment of symptoms, • Sedatives / Opioids if necessary.

26. Delayed Recovery • Systematic evaluation • Pre-op status • Intraoperative events • Ventilation • Response to Stimulation • Cardiovascular status

27. Delayed Recovery • The most common cause: • Residual anesthesia  Consider reversal • Hypothermia, • Metabolic e.g. diabetic coma, • Underlying psychiatric problem • CVA

28. Postoperative Nausea & Vomiting “PONV” • Risk factors • Type & duration of surgery, • Type of anesthesia, • Drugs, • Hormone levels, • Medical problems, • Autonomic involvement.

29. Prevention of PONV • NPO status • Droperidol, • Metoclopramide, • H2 blockers, • Ondansetron, • Acupuncture

30. WHO Algorithm for Management of Pain • + Multidisciplinary: • Adjuvant therapy. • Psychotherapy. • Physioltherapy. • Causal diag. & ttt. + Adjuvant therapy WHO IIIStrong opioids + Adjuvant therapy WHO class IIWeak opioids + Adjuvant therapy WHO class IPNSAIDs

31. Regional Blocks • Local infiltration • Peripheral nerve blocks • Plexus block: • UL: Brachial PB • LL: Lumbar PB • Thoracic: Intercostal, Interpleural, Paravertebral • Epidural: • Thoracic • Lumbar • Caudal

32. PACU Discharge Criteria • Fully Awake, • Patent airway, • Good respiratory function, • Stable vital signs, • Patency of tubes, catheters, IV’s • Pain free, • Reassurance of surgical site.

33. Postanesthesia Discharge Scoring System

34. Post-operative Care “PACU” Thank You