Transcript Postanesthetic care

Postanesthetic care
Recovery room
 Recovery rooms have been inexistence
35-40 years
 As surgical prcedures increasing
complex & sicker patients recovery room
care were extend beyond first few hours
after surgery
 Some critically ill patients were kept in
the RR overnight.
 The success of the RR was a major
factor in the evolution of modern surgical
intensive care unit.
 Now they refer to as post anesthetic care
units (PACU)
 As the conclusion of most operations,
anesthetics agent were discontinued,
monitors were disconnected, and the pt.
were taken to the PACU.
 Pts .are routinely observed in the PACU
following regional& general anesthesia.
 Most guidelines require pt. to admit to
PACU except by specific order of the
attending anesthetist.
 After brief verbal report to the PACU
nurse, th pt. is left in the PACU until the
major effect of anesthesia is worn off.
 This period is high incidence of
potentially life threatening respiratory
&circulatory complications.
Objective of the PACU
 Care &monitor pts. during anesthetic
wear off in the first few hours after
surgery.
 Monitor especialy respiratory &
circulatory complications and vital organ.
 Early detect surgical complication eg.
bleeding, drainage.
 Post op pain
Design
 The PACU should be locate near the OR.
 A central location that the pt. can be rush
back to surgery or need staff can quickly
attend to the pt.
 The transfer critically ill pt. to the elevator
or long corridors can jeopardise this care.
 A ratio of 1.5 bed PACU/OR
Equipments
 Full monitorings
spo2,EKG,NIBP,sphygmomanomitors,
 Capnograph, transducing pressure to direct
arterrial ,CVP ,PCWP ,temperature
 Own supplies basic &emergency equipments.
 Catheter for vascular canulations.
 Oxygen equipments, respiratory therapy
equipments, ventilators
staffing
 The PACU staff only by nurses specific
trained in the care of patients emergence
from anesthesia.
 Expertise in airways management
&ACLS ,commonly problems relate to
wound care, draniage catheter, bleeding.
 Average PACU stay is1-2hours.
Care of the patient,
emergence from general anesthesia
 Recovery from GA&RA is great of physiologic
stress –airways obstruction
-shivering
-agitation
-delilium
-pain
-nausea/vomiting
-autonomic lability loss of
compensation reflex
-hypothermia
 During tarnsport to the recovery room is
frequently airways obstruct, shivering,
agitation, delirium,pain, nausia, vomiting,
hypothermia, autonomic lability.
 RA-decrease in BP, symphatolytic
effects of regional block, loss of reflex
vasoconstriction.
 Speed of emergence in inhalation base
anesthetic depend on alveolar ventilation,
but inverse proportion to blood gas
solubility.
 A duration of anesthesia,total tissue
uptake, agent solubility, concentration use,
nitrus oxide use.
 The most frequent cause of delay
emergence from inhalation anesthesia is
hypoventilation.
 Emergence from intravenous anesthesia is
depend on redistribution rather than
elimination half life.
 Total drug dose& accumulation effect
,advance age, hepatic ,renal disease can
prolong emergence.
 Type &dosage of pre medication, pre op
sleep deprivation ,drug ingest ( alcohol,
sedative)
Delay emergence
 Pts.fail to regain conscious in 60-90
minutes after GA.
 The most frequent cause is residual
anesthetic ,sedative ,analgesic drug effect.
 Antidote naloxone , flumacinil can
exclude opioid&bensodizepine effects.
 Physostigmine can exclude nuromuscular
blockade.
Less common cause of delay
emergence
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Hypothermia esp. core temp<33 c.
Mark metabolic disturbance
Preoperative stroke
Hypoxia/hypercarbia
Hyper ca, hyper mg,hypo Na,hypohyperglycemia
Transport from the operating
room
 Usually complicate by lack of adequate
monitors, drugs ,resuscitive equipments.
 Pt. should not leave unless stable patent
airway, adequate ventilation,&
hemodynamic stable.
 Transport with oxygen supplemment
 The positions also help either head –up,
head –down, lateral position.
Routine recovery from GA
 Vital sign&o2 should be checked immediately on
arrival.
 NIBP,PR,RR routinely every 5min.for 15 min.or
until stable ,and every 15 min. therafter,may be
temperature.
 After check vital signcheck preop history(
include mental status, comunication problem
)intra op event, expected p/o problems ,post
anesthetic order
 All pt. recover from GA should receive 3040% 02 to prevent hypoxia.
 Continue 02 therapy at the time to
discharge base on sp02 reading on room
air.
Routine recovery from RA
 Pt. who heavily sedate or hemodynamic
unstable should receive 02 supplement.
 Check sensory& motor level to document
dissipation of blockade.
 Precaution self injury from un coordinate
extremity.
 Bladder catheterization is need for longer
than 4 hours.
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Pain controle
Agitation
Nausea&vomiting
shivering
Discharge criteria
 Esay arousable
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Full orientation
Stability to maintain&protect airway
Stable vital signs for at least 1 hours
The ability to call for help if necessary
No obvious surgical complications (such
as active bleeding)
Post anesthetic recovery score(PAR
score)/Aldrete score
 Colour-pink/pale or dusky/cyanotic
 Respiration-can breath deeply&cough
-shallow but adequate
-apnea/obstruction
 Circulation-BP within 20%of normal
-20-50% normal
->50% normal
 Consiousness-awake /alert/oriented
-arousable but readily drift back
to sleep
- no response
 Activity –move all extremity
-move 2 extremity
- no movement
*failure of spial / epidural block to resolve after
6 hours possibility spinal cord /epidural
hemaotoma
 Should be discharge when total score10
 Thank you for your attention.