Postanesthesia

recovery
SOFIA UNIVERSITY “ST. KLIMENT OHRIDSKI”
FACULTY OF MEDICINE
DEPARTMENT OF ANESTHESIOLOGY AND INTENSIVE CARE
 Each patient recovering from an anesthetic has circumstances that
require an individualized problem-oriented approach
 Postoperative planning begins with the preoperative evaluation
and formation of an intraoperative anesthetic plan
POSTANESTHETIC TRIAGE

 Patients must be carefully evaluated to determine which level of care is

appropriate.
 Triage should be based on clinical condition, length/type of procedure
and anesthetic, and the potential for complications that require
intervention.
 Alternatives to PACU care must be used in a nondiscriminatory fashion.
 An individual patient undergoing a specific procedure or anesthetic
should receive the same appropriate level of postoperative care
whether the procedure is performed in a hospital operating room, an
ambulatory surgical center, an endoscopy room, an invasive radiology
suite, or an outpatient office.
 If doubt exists about a patient’s safety in a lower-intensity setting, the
patient should be admitted to a higher level of care for recovery.
Patient safety should always be favored regardless of the cost.
 After superficial procedures using local infiltration, minor blocks, or
sedation, patients can almost always recover with less intensive
monitoring and coverage.
 Healthy patients undergoing more extensive procedures (e.g.,
hernia repairs, arthroscopic procedures, minor orthopedic
procedures) under local, plexus, or peripheral nerve blockade might
also bypass phase I recovery and go directly to phase II.
 The increasing use of continuous peripheral nerve catheters for
surgery has shortened PACU time and can eliminate many hospital
admissions.
 Innovative anesthetic techniques, advanced surgical techniques,
and use of bispectral index monitoring help facilitate fast-track
postoperative care.
SAFETY IN THE POSTANESTHESIA
CARE UNIT
 The PACU medical director must ensure that the PACU environment
is as safe as possible for both patients and staff.
 Beyond usual safety policies, maintain staffing and training to ensure
appropriate coverage and skill mix are available to deal with
unforeseen crises.
 Incidence of adverse events in the PACU correlates with nursing
workload and staff availability.
 Less skilled or training staff must be appropriately supervised, and a
sufficient number of certified personnel must always be available to
handle worst-case scenarios.
 The PACU staff protects patients who are temporarily incompetent and
preserves patients’ rights to observance of advanced directives and to
informed consent for additional procedures.
 The staff is obligated to optimize each patient’s privacy, dignity, and to
minimize the psychological impact of unpleasant or frightening events.
 Observance of procedures for hand-washing, sterility, and infection
control should be strictly enforced.
 Medical directors must safeguard against potential for personal assault
of patients during recovery such as unwarranted restraints and
procedures without consent.
 Access to the PACU should be strictly controlled.
 With increasing acceptance of reuniting patients with family/friends,
safety and privacy need to be continually addressed.
The PACU environment must also
be safe for professionals
 Air handling should guarantee that personnel are not exposed to unacceptable
levels of trace anesthetic gases, although trace gas monitoring is not necessary.
 Ensure that staff members receive appropriate vaccinations, including that for
hepatitis B. Practitioners must adhere to policies for radiation safety, infection
control, disposal of sharps, universal precautions for blood-borne diseases, and
safeguarding against exposure to pathogens such as methicillin-
resistant Staphylococcus, vancomycin-resistant Enterococcus, Clostridium
difficile, or tuberculosis.
 Always keep masks, gloves, gowns, eye protection, and appropriate particulate
respiratory equipment easily accessible. Following current infection control
policies and guidelines are essential for patient and staff safety.
 Ensure that sufficient help is available to avoid injury while lifting and positioning
patients or while dealing with emergence situations. Precise documentation and
clear delineation of responsibility is essential for proper care of patients and can
protect staff against unnecessary medicolegal exposure.
ADMISSION TO THE POSTANESTHESIA
CARE UNIT/icu
 Every patient admitted to a PACU should have heart rate, rhythm, systemic
blood pressure, airway patency, peripheral oxygen saturation, ventilatory
rate/character, and level of pain recorded and periodically monitored.
 Document temperature, level of consciousness, mental status, neuromuscular
function, hydration status, degree of nausea on admission/discharge, and more
frequently if appropriate, are also minimum standards of care.
 Every patient should be continuously monitored with a pulse oximeter and at
least a single-lead electrocardiogram (ECG). Extra leads, particularly precordial
V3 to V6, are appropriate if left ventricular ischemia is likely.
 Capnography is necessary for patients receiving mechanical ventilation or
those at risk for compromised ventilatory function.
 Transduction and recorded output from invasive monitors such as central
venous, systemic, or pulmonary arterial catheters must be accomplished.
 Diagnostic (laboratory) testing should be ordered only for specific indications.
POSTOPERATIVE PAIN MANAGEMENT

 Periodically assess and document level of pain throughout recovery.

 Inadequate postoperative analgesia is a major source of preoperative fear/dissatisfaction for surgical patients.
 In addition to improving comfort, analgesia reduces sympathetic nervous system response, thereby avoiding
hypertension, tachycardia, and dysrhythmias. In hypovolemic patients, the sympathetic nervous system activity may well
mask relative hypovolemia.
 Administration of analgesics can precipitate hypotension in an apparently stable patient, especially if direct or histamine-
induced vasodilation occurs.
 It is important to assess a tachycardic patient with low or normal blood pressure who complains of pain carefully before
giving analgesics that might precipitate or accentuate hypotension.
 The actual degree of postoperative pain can be difficult to establish.
 Severity of pain varies among surgical procedures and anesthetic techniques.
 Inexperienced nurses overestimate a patient’s pain, whereas more experienced nurses tend to underestimate the pain.
 The best measure of analgesia is the patient’s perception. Heart rate, respiratory rate and depth, sweating, nausea, and
vomiting all may be signs of pain but their absence or presence is not in itself reliable as a measure of the presence of
pain.
Surgical pain can be effectively
treated with:
 intravenous opioids (assess for incremental respiratory or cardiovascular
depression)
 cyclooxygenase-2 inhibitors has decreased because of adverse cardiovascular
events
 Nonselective nonsteroidal anti-inflammatory drugs such as ibuprofen or
acetaminophen are also effective
 Epidural analgesia
 Continuous flow catheters with pressure delivery systems of local anesthetics
 Transversus abdominis plane (TAP) blocks
 Caudal analgesia or paravertebral blocks can also be effective in children
 Oral and transdermal analgesics have a limited role in the PACU but are helpful
for ambulatory patients after PACU discharge. Rectal analgesics are sometimes
useful in small children.
DISCHARGE CRITERIA

 When possible before discharge from postoperative care, each

patient should be sufficiently oriented to assess his or her physical
condition and be able to summon assistance.
 Airway reflexes and motor function must be adequate to maintain
patency and prevent aspiration.
 One should ensure that ventilation and oxygenation are
acceptable, with sufficient reserve to cover minor deterioration in
unmonitored settings.
 Blood pressure, heart rate, and indices of peripheral perfusion
should be relatively constant for at least 15 minutes and
appropriately near baseline.
 Achieving normal body temperature is not an absolute requirement,
but there should be resolution of shivering.
Extubation

 Indeed, the period of extubation may be far more treacherous than

that of intubation.
 Extubation of the trachea must not be considered a benign
procedure. It is not simply the elimination or reversal of tracheal
intubation.
 Extubation is fraught with its own set of potential complications.
 Appropriately trained personnel and proper equipment should be
immediately available at the time of extubation. This may range
from a postanesthetic care unit nurse or respiratory therapist with a
set of laryngoscopes to a surgeon prepared to perform an
emergency tracheostomy.
 Most adult patients are extubated after the return of consciousness and
spontaneous respiration, the resolution of neuromuscular block, and the ability
of the patient to follow simple commands.
 The patient is asked to open the mouth, and a suction catheter is used to
remove excessive secretions and/or blood. The head of the bed may be placed
in a 10-degree Trendelenburg position. The airway pressure is allowed to rise to 5
to 15 cm of H2O to facilitate a “passive cough,” and the ETT is removed after the
cuff (if present) is deflated.
 If coughing or straining is contraindicated or hazardous (e.g., increased
intracranial pressure), extubation may be performed while the patient is in a
surgical plane of anesthesia and breathing spontaneously.
 In patients at risk for gastric content aspiration (e.g., full stomach) or upper
airway obstruction, the clinician needs to assess the relative risk of each
potential morbidity (e.g., coughing vs. obstruction vs. aspiration).
 Patients who are not fully recovered from neuromuscular relaxation are at risk of
airway obstruction and aspiration at the time of extubation.
Laryngospasm

 Laryngospasm during extubation accounts for 23% of all critical

postoperative respiratory events in adults.
 Laryngospasm may be triggered by:
 respiratory secretions, vomitus, blood, or a foreign body in the airway;
 pain in any part of the body;
 pelvic or abdominal visceral stimulation.
 The cause of airway obstruction during laryngospasm is the contraction
of the lateral cricoarytenoids, the thyroarytenoid, and the cricothyroid
muscles.
 Management of laryngospasm consists of the immediate removal of
the offending stimulus (if identifiable), administration of oxygen with
continuous positive airway pressure, and if other maneuvers are
unsuccessful, the use of a small dose of short-acting muscle relaxants.
Criteria for extubation after general
anestesia
REFERENCES

 Clinical Anesthesia, seventh edition, Paul G. Barash, ISBN-13: 978-1451144192;

 Miller's Anesthesia, seventh edition, Ronald D. Miller MD MS, ISBN-13: 978-0702052835;

 Morgan and Mikhail's Clinical Anesthesiology, 5th edition, John Butterworth, ISBN-13: 978-0071627030.