Post operative management
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Post-Operative Managment β’ The post operative period begins from the time β’ The patients leaves the operating room and ends with the follow up visit by the surgeon. β’ The post operative care is provided by -- PACU -- SICU
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Post operative management
- 1. Post-Operative Management Mr. Harshad Khade MSc. Medical Technology (OTA) Symbiosis International university, Pune.
- 2. Introduction β’ The post operative period begins from the time β’ The patients leaves the operating room and ends with the follow up visit by the surgeon. β’ The post operative care is provided by -- PACU -- SICU
- 4. Purposes β’ To enable a successful and faster recovery of the patients post operatively. β’ To reduce post operative mortality rate. β’ To reduce the length of hospital stay of the patient. β’ To provide quality care service. β’ To reduce hospital and patients cost during post operative period.
- 5. Post Operative Care Unit Post Anesthetic Care Unit
- 6. Post Operative Care Unit Post Anesthetic Care Unit β’ Patients still under anesthesia or recovering from anesthesia are placed in the unit for observation by highly skilled nurses, Anesthetist and Anesthesia technologist. β’ PACU should be sound proof, painted in soft colures will help the patient to reduce anxiety and promote comfort.
- 7. PACU Definition : it is the β’ Specially designated β’ Specially designed β’ Specially located β’ Specially staffed β’ Specially equipped For a specific purpose.
- 9. PACU Location β’ Should be located close to the operating theater. β’ Immediate access to X-Ray, blood bank, blood gas and clinical lab. β’ An open ward is optimal for patients observation, either at least one isolation room. β’ Central nursing station. β’ Requires good ventilation, because the exposure to waste anesthetic gases may be hazardous.
- 10. Design Of PACU
- 11. Design Of PACU Size :- β’ Ideal 1.5 ( 3:2 ) PACU beds for every operating room β’ 80 - 120 square foot per patients. β’ Minimum of 7 feet distance between beds. Facilities :- β’ Fowlerβs cot with side rails. β’ Piped oxygen, vacuum and air. β’ Multiple electrical outlets β’ Large doors. β’ Good lighting β’ Isolation for immune compromised patients.
- 12. PACU Staffing
- 13. PACU Staffing β’ One nurse to one patient for the first 15 minutes of recovery. β’ Then one nurse for every two patients. β’ The anesthesiologist responsible for the anesthetic remains responsible for managing the patient in the PACU. β’ Adequate no. of ancillary staff, such as technicians, ward boys and female attenders.
- 14. PACU Equipment
- 15. PACU Equipment β’ Multi-parametric monitors ( automated NIBP, SPO2, ECG ) and Intravenous supports should be located at each bed. β’ Area for charting, bed side supply storage, suction and oxygen flow meter at each bed side. β’ Immediately available- β’ Emergency equipment, β’ crash cart, β’ Defibrillator.
- 16. Transport Of Patient From OR To PACU
- 17. Transport Of Patient From OR To PACU β’ Avoid exposure β’ Avoid rough handling β’ Avoid hurried movement and rapid changes in position. Criteria for shifting patient from OR to PACU 1. Hemodynamic stability. 2. Clinical evaluation and complete recovery from NM blockade. 3. Maintenance of oxygen saturation 4. Normothermia
- 18. PACU Standards
- 19. 1. All patients who hav 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 anesthesia care team that is knowledgeable about the patients condition. (Anesthesia Technologist) 3. Upon arrival in the PACU, the patient should be re-evaluated and verbal report should be provided to the nurse. 4. The patient shall be evaluated continually in the PACU. 5. Anesthesiologist concerned is responsible for discharge of the patient.
- 20. Phases Of Post Operative Unit
- 21. Phases Of Post Operative Unit PHASE I β’ It is the immediate recovery phase and requires intensive nursing care to detect early signs of complications. β’ Receive a complete patient record from the operating room which to plan post operative care. β’ It is designed for care of surgical patient immediately after surgery and patient requiring close monitoring. PHASE II β’ Care of the surgical patient who has been transferred from the phase I post operative unit. β’ Patient requiring less observation and less nursing care then phase I. β’ This phase is also known as step down or progressive care unit.
- 22. Admission Report β’ Preoperative history β’ Intra-operative factors: 1. Procedure 2. Type of anesthesia 3. Estimated Blood loss 4. Urine output β’ Assessment and report of current status β’ Post operative instructions
- 24. Post-operative Pain Management β’ Intravenous opioids β’ Diclofenac, I.V. Paracetamol and Anti Inflammatory drugs. β’ Midazolam for anxiety. β’ Epidural : Local Anesthetic Agentβs and their adjuvant. β’ Regional analgesic blokes. β’ PCA ( Patient controlled analgesia)
- 25. PACU Length Of Stay
- 26. PACU Length Of Stay β’ Will vary, is dependent upon several factors. β’ Type of surgery, β’ patients response to surgery and anesthesia, β’ medical history. β’ Average length of stay is 2 to 3 hours. β’ Longer stays may be necessary to meet discharge criteria.
- 27. β’ Patient may feel the following up to 24 hours β’ Sore throat β’ Aching muscles β’ General malaise β’ Shivering β not uncommon β’ Warm cotton blankets applied as necessary β’ Warm air blanket may be utilized β’ Medication is used for extreme shivering
- 29. Management In PACU β’ To provide care until the patient has recovered from the effect of anesthesia β’ Assessing the patient β’ Monitor vitals- β’ Pulse volume and regularity, β’ depth and nature of respiration, β’ Assessment of patients o2 saturation. β’ Skin color.
- 31. Check The Level Of Consciousness Ability To Respond To Commands
- 32. Maintain Intake And Output
- 34. Protect Airway β’ By proper positioning of patients head. β’ By clearing airway. β’ Oxygen therapy Pharyngeal obstruction β’ Can occur when the patient lies on the back as there are chances for tongue to all back.
- 35. Maintaining I.V. Stability β’ Hypovolemic shock can be avoided by timely administration of IV fluids, blood and blood products and medication. β’ Replacement of fluids colloids and crystalloids. β’ Monitor intake and output balance.
- 36. Assessment Of The Surgical Site Hemorrhage β’ It is a serious complication of surgery that can results in death. β’ It can occur in immediate post operatively or up to several days after surgery. β’ If left untreated cardiac output decreases and blood pressure and Hb level be fall rapidly.
- 37. Keep The Patient Warm β’ Use warmer ( Bair Hugger ) blankets β’ Use warm lights.
- 38. Post Operative Complication β’ Nausea and vomiting β’ Respiratory complications β’ Failure to regain consciousness β’ Circulatory complications β’ Fever
- 39. Discharge Criteria From PACU
- 40. Discharge Criteria From PACU β’ Neither an arbitrary time limit nor a discharge score can be use to define a medically appropriate length stay in the PACU accurately. β’ All patients must be evaluated by anesthesiologist / anesthesia technologist prior to discharge from PACU. β’ Criteria for discharge developed by the anesthesia department. β’ Criteria depends on where the patient is sentβWard, ICU, Home.
- 41. Discharge Criteria From PACU β’ Full orientation β’ Ability to maintain & protect airway β’ Stable vital signs for at least 15 β 30 minutes. β’ The ability to call for help if necessary. β’ No obvious surgical complication (active bleeding )
- 43. Discharge From PACU β’ Standard Aldrete score: β’ Simple sum of numerical values assigned to activity, respiration, circulation, consciousness and oxygen saturation. β’ A score 9 out of 10 shows readiness for discharge. Post-Anesthetic discharge score system: β’ Modification of the Aldrete score which also includes an assessment of pain, nausea, vomiting and surgical bleeding in addition to vital signs and activity β’ also a score of 9 or 10 shows readiness for discharge.
- 44. Aldrete Score
- 45. Points Activity Respiration Circulation Consciousness Oxygen Saturation 2 Moves All Extremities (Voluntarily / On Command) Breaths Deeply And Coughs Freely BP + 20 mm Of Pre Anesthetic Level Fully Awake Spo2 >92% On Room Air 1 Moves 2 Extremities' Dyspneic Shallow Limited Breathing BP + 20-50 mm Of Pre Anesthetic Level Arousable On Calling Supplemental O2 Required To Maintained Spo2>90% 0 Unable To Move Extremities Apneic BP + 50 mm Of Pre Anesthetic Level Not Responding Spo2 < 92% With O2 Supplementation
- 46. Interpretation Of Aldretes Score β’ Lowest score = 0-2 β’ Score for patient to be shifted to next level of care = 9 Sinece 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 in to account the anesthetic plan & the drugs given intra-operatively as well as in PACU.
- 47. Post-anesthetic Discharge Score System (PADS) Points Vital sign (BO & Pulse) Activity Nausea & vomiting Pain Surgical Bleeding 2 Within 20% of preoperative baseline Steady gait no dizziness Minimal Acceptable control per the patient Minimal 1 20-40% of preoperative baseline Requires assistance Moderate Not acceptable to the patient Moderate 0 >40% of preoperative baseline Unable to ambulate continues Severe
- 48. Discharge From Post Operative Unit
- 49. β’ A patient remains in the post operative unit, until the patients has fully recovered from anesthesia. β’ Following measures are used to determine the patient ready for discharge from post operative unit β’ stable vital signs β’ Orientation to : Person, place,Time . β’ Adequate oxygen saturation level β’ Urine output at least 30 ml/hour β’ Minimal pain β’ Adequate respiratory function. β’ Aldrete score more than β9β
- 51. Teaching Patient Self Care β’ Expected outcome β’ Immediate post operative changes β’ Writen instruction like wound care, β’ Activity + dietary recommendation β’ medications β’ follow up
- 53. Safe Guidelines For Discharging To Home After Ambulatory Surgery β’ Patient should be able to stand & take a few steps β’ Should be able to sip fluids β’ Should be able to urinate β’ Should be able to repeat post operative management β’ Should be able to identify the escort (cognitive function)
- 55. Summary β’ Anesthesia is becoming very sophisticated ! β’ PAC is an absolutely essential care given by a team of professionals ! β’ Anesthesiologist and Anesthesia Technologist are the most important members of PACU ! β’ Through understanding of pathophysiology of this period is very essential ! β’ With well organized PACU, one can prevent lot of post operative morbidity & mortality !