Recovery room lecture

1. PACU
-Post Anesthesia Care Unit-
Helga Komen, MD
Instructor
Department of Anesthesiology
Washington University in St. Louis

2. PACU
• Post Anesthesia Care Unit is the area
designated for the monitoring and care
of patients who are recovering from the
immediate physiologic derangements
produced by anesthesia and surgery
• Recovery room
Post Anesthesia Care Unit

3. PACU
• Bridges the period leading to:
– full return of conciousness
– full return of protective airway reflexes
– resumption of cardiovascular stability
• Monitoring of bleeding, nausea, hypothermia
• Pain relief
- 1-2 hour stay
Post Anesthesia Care Unit

4. • Module A, B, C
Post Anesthesia Care Unit
PACU

5. PACU - History
• Methods of anesthesia have been available for more
than 160 years
– PACU has only been common for the past 50 years !
• 1920’s/30’s - several PACU’s opened in the US and abroad.
• After WW II the number of PACU’s increased significantly.
• 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.
Post Anesthesia Care Unit

6. Standards for PACU
Post Anesthesia Care Unit
 1. All patients who have received general anesthesia,
regional anesthesia, or monitored anesthesia care should
receive postanesthesia 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. A physician is responsible for discharge of the patient.

7. PACU – requirements/space
• Should be located close to the operating suite
• Should have 1.5 PACU beds per operating room used
• 120 square foot per patient
• Minimum 7 feet between beds
Post Anesthesia Care Unit

8. • Central nursing station
• 1 : 1 ratio good
• 1 : 3 ratio acceptable for busy OR’s
Post Anesthesia Care Unit
PACU – requirements/personel

9. Post Anesthesia Care Unit
• Monitors:
–ECG
–Pulse oximeter
–EtCO2
–Non invasive BP
–Invasive pressure monitor
–Temperature
PACU – requirements/equipment

10. Post Anesthesia Care Unit
• Tray with labeled Emergency drugs
• Airway maintenance kit:
– Laryngoscope (all size blades)
– Endotracheal tubes (all sizes)
– Face masks, Airways, Ambu Bag, Venturi masks
– Cricothyroidotomy set
– Tracheostomy set
– Transport ventilator
PACU – requirements/equipment

11. • Immediate access to
– clinical labs (ABG)
– x-ray
– blood bank
• Piped in
– Oxygen
– Air
– Vacuum for suction
• Requires good ventilation (waste anesthetic gases)
Post Anesthesia Care Unit
PACU – requirements/equipment

12. Criteria for shifting from OR---to---PACU
Post Anesthesia Care Unit
Patient is:
– Conscious, awake, responds to simple commands
– Haemodynamically stable
– Maintains oxygen saturation
– Clinical evaluation for NM blockade recovery
– Normothermic

13. Standards for PACU
Post Anesthesia Care Unit
 1. All patients who have received general anesthesia,
regional anesthesia, or monitored anesthesia care should
receive postanesthesia 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. A physician is responsible for discharge of the patient.

14. Post Anesthesia Care Unit
Transportation from OR---to---PACU
• Stretcher/bed with side rails
• O2 tank
• Monitoring – SpO2, HR
• Anaesthesiologist + Surgeon

15. On Admission to PACU
• Anaesthetist to PACU nurse hand over
– Preoperative history
– Intra-operative factors:
 Procedure
 Type of anesthesia
 EBL
 UOP
– Assessment and report of current status
– Post-operative instructions
Post Anesthesia Care Unit

16. Post Anesthesia Care Unit

17. Standards for PACU
Post Anesthesia Care Unit
 1. All patients who have received general anesthesia,
regional anesthesia, or monitored anesthesia care should
receive postanesthesia 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. A physician is responsible for discharge of the patient.

18. Admission in PACU
• Monitoring equipment attached
Cardiac monitor
Blood pressure cuff (or IBP)
Pulse oximetry
• Oxygen (nasal canula/mask) – 2-5 L/min
• Surgical site examined
• Intravenous fluids/iv line checked
• Vital signs
– taken every 5 minutes (for 30 min)
– …..every 15 minutes afterwards
Post Anesthesia Care Unit

19. Standards for PACU
Post Anesthesia Care Unit
 1. All patients who have received general anesthesia,
regional anesthesia, or monitored anesthesia care should
receive postanesthesia 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. A physician is responsible for discharge of the patient.

20. …in the PACU - PHASE I
All patients must be observed on a one-to-
one basis until they have regained control of
their airway, have stable cardiovascular and
respiratory systems and are awake and able
to communicate.
Immediate post-anaesthesia recovery 2013
Association of Anaesthetists of Great Britain and Ireland
Membership of the Working Party: D. K. Whitaker (Chair),
H. Booth,3 P. Clyburn, W. Harrop-Griffiths, H. Hosie,1
B. Kilvington,3 M. MacMahon, P. Smedley2 and R. Verma4
Post Anesthesia Care Unit

21. Post Anesthesia Care Unit
Postoperative complications
Nausea and Vomiting
• Most common complication in the PACU
• May be more frequently seen after
• laparoscopic surgeries
• strabismus surgeries

22. • DDX:
– Narcotics/ volatile anesthetics/ etomidate
– Hypoxia
– Hypotension
– Pain
– Anxiety
– Infection
– Chemotherapy
– Gastrointestinal obstruction
– Movement
– Vagal response
– Pregnancy
– Increased ICP
• Do:
– IV fluids
– Medications – Zofran (ondansetron)/ dexamethasone / diphenhydramine/
promethazine/prochlorperazine
– Metoclopromide 0.15mg/kg IV
Post Anesthesia Care Unit
Postoperative complications
Nausea and Vomiting

23. Post Anesthesia Care Unit
• 2/3 of major anesthesia-related incidents may be
respiratory
• Airway obstruction
• Secretions
• Sagging tongue: treated with triple maneuver
• Laryngeal Spasm:
– Due to secretions
– Due to irritable airways (smokers)
• Rx: 100% Oxygen through face mask
• Hydrocortisone 100 mg IV
• If no improvement rapid intubation to secure the
airway (succinylcholine)
Postoperative complications
Respiratory complications

24. Post Anesthesia Care Unit
• Hypoxemia
• Hypoventilation
–Inadequate N.M. blockade recovery
–Respiratory depressant effect of volatile
agents, narcotics, benzodiazepines
–Upper abdominal incisions – pain!
Postoperative complications
Respiratory complications

25. Post Anesthesia Care Unit
• Hypoxemia
– Increased Right to Left Shunt:
• Atelectasis
– Inadvertent endobronchial intubation
– Ateclectasis of the lung
– Blockage of brochus by blood or mucous plug
– Pneumothorax:
• following rib injury
• following CVP placement
– Chest X-ray routinely done in the PACU
• Post laparoscopic surgery
Postoperative complications
Respiratory complications

26. Post Anesthesia Care Unit
• Th:
– 02 10 L/min
– See the patient!
– Assess vital signs and respiratory rate.
– Evaluate the airway. R/o obstruction or foreign
body.
– Mask ventilate with Ambu if necessary.
– Intubate and secure the airway.
– Look for causes of hypoxia.
• Send ABG, CBC, BMP. Get CXR.
Postoperative complications
Respiratory complications

27. • Pain is a common occurrence and should be anticipated
– NRS - Numeric Rating Scale
0-10
– The PACU nurse will treat pain until comfort is obtained (NRS 3-5)
– fentanil, hydromorphone
– PCA
– Regional anesthesia
– Pain free – unrealistic!
Post Anesthesia Care Unit
Postoperative Pain Management

28. Post Anesthesia Care Unit
Hypotension
• Decreased preload
– Increased blood loss
– Increased III space loss
– Septicemia
• Decreased myocardial contractility
– Depressant effect of GA drugs
– Pre-existing ventricular dysfunction
– Perioperative Myocardial infarction!!
Postoperative complications
Circulatory Complications

29. Post Anesthesia Care Unit
Hypertension:
–Pre-existing poorely controled
hypertension!
– Pain
– Hypercapnia
– Hypothermia
– Hypoxemia
Th: analgetics, metoprolol (MAP and HR ↓) , labetalol
(MAP↓), hydralazine
Postoperative complications
Circulatory Complications

30. Post Anesthesia Care Unit
Arrythmias:
–Electrolyte imbalance ( K )
–Hypoxia
–Hypercarbia
–Metabolic acidosis
Postoperative complications
Circulatory Complications

31. Post Anesthesia Care Unit
Myocardial ischemia
– Increased risk:
• History of CAD
• CHF
• Smoker
• HTN
• Tachycardia
• Severe hypoxemia
• Anemia
– Same risk if the patient has GA or regional anesthesia.
Postoperative complications
Circulatory Complications

32. Treatment (ACS)
• Oxygen, ASA, NTG, morphine if needed
• 12 lead EKG
• History
• Consult cardiology
Post Anesthesia Care Unit
Postoperative complications
Circulatory Complications

33. Shivering
– Not uncommon – 65% with GA, 33% with EPA
– Mechanism – decrease in body temp., uninhibited
spinal reflexes (clonic activity)
Th:
– Warm cotton blankets applied as necessary
– Warm air blanket may be utilized
– Medication is used for extreme shivering - Inj.
meperidine 12.5-25mg IV
Post Anesthesia Care Unit
Postoperative complications

34. • Over 14 years of age
• Limit visit to 5 minutes
• Feel comfortable in a medical setting
• Are willing to follow directions from PACU staff
• Use hand sanitizers as enter and leave PACU
Post Anesthesia Care Unit
Family presence in PACU

35. PACU Length of Stay
• Average length of stay is 1 - 3 hours
• Will vary - dependent upon several factors:
– type of surgery
– patient’s response to surgery and anesthesia
– medical history
• Longer stays may be necessary to meet discharge
criteria
• Criteria depends on where the patient is sent – ward,
ICU, home
Post Anesthesia Care Unit

36. • General anesthesia – awake
• Spinal – moving (bend knees) and able to feel legs
– Vital signs stable
– Pain controlled
– Nausea and vomiting controlled if present
– Body temperature normal
• Discharged by anesthesiologist when criteria met !
Post Anesthesia Care Unit
PACU Length of Stay
Discharge criteria

37. Discharge criteria
Post Anesthesia Care Unit
 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.
 Postanesthesia 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.

38. Post Anesthesia Care Unit
Aldrete Score

39. Post Anesthesia Care Unit

40. PHASE II
• This phase focuses on preparing the patient
and family for care in the home, or an
extended care environment.
Module F
Post Anesthesia Care Unit

41. Post Anesthesia Care Unit
Discharging 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)

42. References
• Robert K. Stoelting. Basics of Anesthesia. Fifth
edition. 2007.
• M. Avidan and auth. Perioperative Care, Anesthesia,
Pain Managment and Intensive Care. 2003.
• ASA - https://www.asahq.org/
• ANSAP - Association of Nursing Service Administrators
Post Anesthesia Care Unit

43. Questions?
Post Anesthesia Care Unit