Post anesthesia care unit(PACU)

ATLAS HOSPITAL
P.O BOX 1101, Postal Code : 133, MBD East,
RUWI. Sultanate Of Oman.
Phone: 24811706
Fax:24811812
Email: atlashospital@gmail.com
12/4/2015 3:47:40 PM

HOSPITALS
Life Long Health Care
www.AtlasEra.com

During The Presentation
PLEASE:
• Put cell-phones on silent/vibrate mode.
• Take emergency calls outside.
• Maintain silence.
HOSPITALS

Post- Anaesthesia Care
(PAC)
DR RAJESH T EAPEN
ANESTHESIOLOGIST
ATLAS HOSPITAL, RUWI

Introduction
 Recovery from anesthesia can range from
completely uncomplicated to life-threatening.
 Must be managed by skilled medical and
nursing personnel.
 Anesthesiologist plays a key role in optimizing
safe recovery from anesthesia
 Must be carried out in a well planned, protocol
based fashion
2/4/2015 3:47:52 PM 5

PAC
Definition
It is the specialized care given
to the patients who have
undergone anaesthetic
management, by a team of
well trained professionals, in a
specially designed, equipped
and designated area of the
hospital
2/4/2015 3:47:52 PM 6

PURPOSES
To enable a successful and faster recovery of
the patient post operatively.
To reduce post operative mortality rate.
To reduce the length of hospital stay of the
patient.
To provide quality care service.
To reduce hospital and patient cost during
post operative period.
2/4/2015 3:47:53 PM 7

PAC Vs. Post operative care
PAC is provided to
 anyone who has undergone anaesthesia
 anaesthesia might not be for a surgical
procedure
 patients undergoing ECT, Narco analysis
 patients under going Endoscopies
+
 all the patients who have undergone
surgeries
2/4/2015 3:47:53 PM 8

PACU
Definition : It is the
 Specially designated
 Specially designed
 Specially located
 Specially staffed
 Specially equipped
for a
 Specific purpose !
2/4/2015 3:47:53 PM 9

History of the PACU
 Methods of anesthesia have been available for more
than 160 years, but the PACU has only been common
for the past 70 years.
 One can trace it to “Lady of the lamp”: F. N.
 1920’s and 30’s: several PACU’s opened in the US and
abroad.
 It was not until after WW II that the number of PACUs
increased significantly. This was due to the shortage of
nurses in the US.
 In 1947 a study was released which showed that over an
11 year period, nearly half of the deaths that occurred
during the first 24 hours after surgery were preventable.
 1949: having a PACU was considered a standard of
care.
2/4/2015 3:47:55 PM 10

PACU Location
 Shouldbe locatedclose to the OperatingTheater
 Immediateaccess to x-ray, bloodbank,bloodgas and clinical
labs.
 An openwardis optimalfor patientobservation,with at least
oneisolationroom.
 Centralnursingstation.
 Requiresgoodventilation,becausethe exposureto waste
anestheticgasesmay be hazardous.
 NationalInstituteof OccupationalSafety (NIOSH) has
establishedrecommendedexposurelimitsof 25 ppm for
nitrousoxide and2 ppm for volatileanesthetics.
2/4/2015 3:47:55 PM 11

Design of PACU
 Size:
 Ideal 1.5 PACU bed for every Operating Room
 120 square foot per patient
 Minimum of 7 feet between beds
 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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PACU
 PACU should be sound
proof, painted in soft colour,
isolated and these features
will help the patient to
reduce anxiety and promote
comfort.
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PACU Staffing
 One nurse to one patient for the first 15
minutes of recovery.
 Then one nurse for every two patients.
 The anesthesiologist responsible for the
anesthetic remains responsible for managing
the patient in the PACU.
 Adequate no. of ancillary staff, such as
technicians, ward boys and female attenders.
2/4/2015 3:47:56 PM 17

PACU Equipment
 Multi-parametric monitors (Automated BP,
pulse ox, ECG) and intravenous supports
should be located at each bed.
 Area for charting, bed-side supply storage,
suction, and oxygen flow meter at each bed-
side.
 Immediately available - Emergency
equipment, Crash cart, Defibrillator.
2/4/2015 3:47:56 PM 18

Routine Post-Anaesthesia Care
 Criteria for shifting from
OR---to---PACU
 Haemo dynamic stability
 Clinical evaluation and
complete recovery from
NM blockade
 Maintenance of Oxygen
Saturation
 Normothermia
2/4/2015 3:47:56 PM 20

PACU Standards
 1. All patients who have received general anesthesia,
regional anesthesia, or monitored anesthesia care
should receive post-anesthesia management.
 2. The patient should be transported to the PACU by
a member of the anesthesia care team that is
knowledgeable about the patient’s condition.
 3. Upon arrival in the PACU, the patient should be re-
evaluated and a verbal report should be provided to
the nurse.
 4. The patient shall be evaluated continually in the
PACU.
 5. Anaesthesiogist, concerned is responsible for
discharge of the patient.
2/4/2015 3:47:56 PM 21

PHASES OF POST OP UNIT
Two phases-
 Phase I
 Phase II
2/4/2015 3:47:56 PM 22

Phase I
 It is the immediate recovery phase
and requires intensive nursing care
to detect early signs of complication.
 Receive a complete patient record
from the operating room which to
plan post operative care.
 It is designated for care of surgical
patient immediately after surgery
and patient requiring close
monitoring
2/4/2015 3:47:56 PM 23

Phase II
 Care of the surgical patient who has
been transferred from the Phase I
post op unit.
 Patient requiring less observation
and less nursing care than Phase I
 This phase is also known as Step
down or progressive care unit.
2/4/2015 3:47:56 PM 24

Admission Report
 Preoperative history
 Intra-operative factors:
 Procedure
 Type of anesthesia
 Estimated Blood Loss (EBL)
 Urine output
 Assessment and report of current status
 Post-operative instructions
2/4/2015 3:47:56 PM 25

Postoperative Pain Management
 Intravenous opioids
 Diclofenac, I.V. Paracetamol and anti-
inflammatory drugs
 Midazolam for anxiety
 Epidural : LAAs and their adjuvants
 Regional analgesic blocks
 PCA (Patient controlled analgesia) and PCEA
2/4/2015 3:47:56 PM 26

NURSING MANAGEMENT IN POST
OP UNIT
To provide care until the
patient has recovered from
the effect of anesthesia.
Assessing the patient
 Monitor vitals-pulse volume
and regularity, depth and
nature of respiration.
 Assessment of patient’s O2
saturation.
 Skin colour.
2/4/2015 3:47:57 PM 32

KEEP MONITORING VITALS
2/4/2015 3:47:57 PM 33

Check the level of consciousness.
Ability to respond to commands.
2/4/2015 3:47:57 PM 34

MAINTAIN INTAKE AND OUTPUT
2/4/2015 3:47:57 PM 35

Protect airway
 By proper positioning of
patient’s head.
 By clearing airway.
 Oxygen therapy.
Pharyngeal obstruction
can occur when the
patient lies on the back
as there are chances for
tongue to fall back.
2/4/2015 3:47:57 PM 36

Maintaining IV Stability
Hypovolemic shock: can be
avoided by timely administration of
IV Fluids, blood and blood
products and medication.
 Replacement of fluids.[colloids
and crystalloids]
 Monitor intake and output balance.
2/4/2015 3:47:57 PM 37

ASSESSMENT OF THE SURGICAL SITE
 Hemorrhage
It is a serious
complication of surgery
that can result in death.
 It can occur in
immediate post
operatively or up to
several days after
surgery.
 If left untreated cardiac
output decreases and
blood pressure and Hb
level will fall rapidly.
2/4/2015 3:47:57 PM 38

 Blood transfusion if
necessary.
 The surgical site + incision
should always be inspected.
 If bleeding- pressure dressing
placed.
 If the bleeding is concealed,
the patient is taken in OR for
emergency exploration of
concealed hemorrhage in
body cavity.
2/4/2015 3:47:57 PM 39

KEEP THE PATIENT WARM
 Use warmer(Bair
Hugger) blankets
 Use warm lights
2/4/2015 3:47:58 PM 40

Relieving pain +Anxiety
 Administer opioid
analgesia as per
Doctor’s order.
 Epidural analgesia.
 NSAIDS.
 Psychological support to
relieve fear+To give
support.
2/4/2015 3:47:58 PM 41

Post Operative Complications
 Nausea and Vomiting
 Respiratory Complications
 Failure to Regain Consciousness
 Circulatory Complications
 Fever
2/4/2015 3:47:58 PM 42

Controlling Nausea + Vomiting
 This is common
problem in post
operative period.
 Medication can be
administered as per
doctor’s order.
Example:
Inj Metoclopramide
Inj Ondansetron
(Emeset /Zofran)
2/4/2015 3:47:58 PM 43

Discharge criteria from PACU
 Neither an arbitrary time limit nor a discharge
score can be used to define a medically
appropriate length stay in the PACU accurately
 All patients must be evaluated by
anesthesiologist/trained staff prior to discharge
from PACU
 Criteria for discharge developed by the
Anesthesia department
 Criteria depends on where the patient is sent –
ward, ICU, home
2/4/2015 3:47:58 PM 47

Discharge criteria from PACU
 Easy arousability
 Full orientation
 Ability to maintain & protect airway
 Stable vital signs for at least 15 – 30
minutes
 The ability to call for help if necessary
 No obvious surgical complication (active
bleeding)
2/4/2015 3:47:58 PM 48

Discharge From the PACU
 Standard Aldrete Score:
 Simple sum of numerical values assigned to
activity, respiration, circulation, consciousness,
and oxygen saturation.
 A score of 9 out of 10 shows readiness for
discharge.
 Post-anesthesia Discharge Scoring System:
 Modification of the Aldrete score which also
includes an assessment of pain, N/V, and surgical
bleeding, in addition to vital signs and activity.
 Also, a score of 9 or 10 shows readiness for
discharge.
2/4/2015 3:47:58 PM 49

ALDRETE SCORE
Post-Anesthesia Score
A total discharge score of 8-10 is necessary
Post-Anesthesia Score
PRE-ANESTHESIA VITAL SIGNS/SOURCE TIME ADM 15" 30" 45" 1' 2' 3' 4' DISCHARGE
SYSTOLIC BP 20% OF PRE-ANESTHETIC LEVEL
2
CIRCULATION 20-50% 1
> 50 0
FULLY AWAKE 2
CONCIOUSNES
S
AROUSABLE ON CALLING 1
NOT RESPONDING 0
WARM, DRY SKIN W/ PREPROCEDURAL
COLORING 2
COLOR PALE, DUSKY, BLOTCHY, JAUNDICED, OTHER
1
CYANOTIC 0
ABLE TO DEEP BREATHE & COUGH FREELY
2
RESPIRATION DYSPNEA OR LIMITED BREATHING APKEIC
1
0
ABLE TO MOVE 4 EXTREMITIES 2
ACTIVITY ABLE TO MOVE 2 EXTREMITIES 1
ABLE TO MOVE 0 EXTREMITIES 0
COMMENTS TOTAL2/4/2015 3:47:58 PM 50

Aldrete Score
Activity Respiration Circulation Consciousness Oxygen
Saturation
2: Moves all
extremities
voluntarily/ on
command
2:Breaths deeply
and coughs
freely.
2: BP + 20 mm of
pre-anesthetic
level
2:Fully awake 2: Spo2 > 92%
on room air
1: Moves 2
extremities
1: Dyspneic,
shallow or limited
breathing
1: BP + 20-50 mm
pre-anesthetic
level
1: Arousable on
calling
1:Supplemental
O2 required to
maintain Spo2
>90%
0: Unable to
move
extremities
0: Apneic 0: BP + 50 mm of
preanestheic level
0: Not responding 0: Spo2 <92% with
O2
supplementation
2/4/2015 3:47:58 PM 51

2/4/2015 3:48:01 PM 52
Interpretation of Aldrete’s score
 Lowest score = 0 – 2
 Score for patient to be shifted to next level of
care = 9
 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

Post-anesthesia Discharge Scoring
System (PADSS)
Vital Signs
(BP and
Pulse)
Activity Nausea and
Vomiting
Pain Surgical
Bleeding
2: Within 20% of
preoperative
baseline
2: Steady gait,
no dizziness
2: Minimal: treat
with PO meds
2: Acceptable
control per the
patient;
controlled with
PO meds
2: Minimal: no
dressing
changes
required
1: 20-40% of
preoperative
baseline
1: Requires
assistance
1: Moderate:
treat with IM
medications
1: Not
acceptable to the
patient; not
controlled with
PO medications
1: Moderate: up
to 2 dressing
changes
0: >40% of
preoperative
baseline
0: Unable to
ambulate
0: Continues:
repeated
treatment
0: Severe: more
than 3 dressing
changes
2/4/2015 3:48:01 PM 53

Discharge from the Post Operative Unit
A patient remains in the post op unit, until
the patient has fully recovered from
anesthesia.
Following measures are used to
determine the patient ready for
discharge from post operative unit:-
 Stable vital signs
 Orientation to Person, Place
Time or events
 Adequate oxygen saturation level.
 Urine out put at least 30ml/hour
 Minimal pain.
 Adequate respiratory function.
 Aldrete score more than ‘ 9 ‘
2/4/2015 3:48:01 PM 54

Teaching, Patient Self Care
 Expected out comes
 Immediate post
operative changes
 Written instructions like
Wound care
Activity+dietary
recommendation
Medications
Follow up
2/4/2015 3:48:01 PM 55

Safe guidelines for discharging to
home 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)
2/4/2015 3:48:01 PM 56

Summary & Conclusion
 Anaesthesia is becoming very sophisticated!
 PAC is an absolutely essential care given by a
team of professionals!!
 Anaesthesiologists and Trained nursing staff
are the most important members of PACU!!!
 Thorough understanding of pathophysiology of
this period is very essential!!!!
 With a well organized PACU, one can prevent
lot of post-operative morbidity & mortality!!!!!!
2/4/2015 3:48:01 PM 57

Post anesthesia care unit(PACU)

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