POST ANAESTHESIA CARE UNIT (PACU)

DR.SHAILENDRA.V.L. SPECIALIST IN ANAESTHESIA. AL BUKARIYA GENERAL HOSPITAL.

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Introduction
Importance of PACU Adequate preparedness Sudden complication

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History of PACU
1947: Anaesthesia Study Commission report Experience of trauma management in 2nd World War Advances in Surgery in 50s and 60s Day care surgery concept of the 90s

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Design of PACU
Location:
Close to Operating Rooms Easy access to Lab, X-ray, Blood bank Close to ICU

Size:
Ideal 1.5 PACU bed for every OR 120 square foot per patient Minimum of 7 feet between beds
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Design of PACU
Facilities:
Fowlers 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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Equipments in PACU
Tray with labeled Emergency drugs Airway maintenance kit:
Laryngoscope with all size blades All sizes Endotracheal tubes Face masks, Airways, Ambu Bag, Venturi masks Tracheostomy set ICD set Transport ventilator
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Equipments in PACU
Personnel:
Requirement varies 1 : 1 ratio good 1 : 3 ratio acceptable for busy ORs

Monitors:
ECG Pulse oximeter Non invasive BP EtCO2 Invasive pressure monitor Temperature

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Routine Post-Anaesthesia Care

Criteria for shifting from OR---to---PACU
Conscious, awake, responds to simple commands Haemo dynamic stability Clinical evaluation for NM blockade recovery Maintainance of Oxygen Saturation Normothermia

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Transportation to PACU
Fowlers cot with side rails Patient handed over to PACU nurse by the Anaesthesiologist

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Care in PACU
Monitoring : ECG, SpO2, Blood pressure Oxygen therapy Pain therapy, anti-emetics Blood Pressure recording:
Every 5 minutes for 30 minutes Every 15 minutes for next 30 minutes

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Post Operative Complications

Respiratory Complications:
Airway obstruction Hypoxemia Increased Left to Right shunt

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Post Operative Complications

Airway Obstruction:
Sagging tongue: Treated with triple maneuver

Laryngeal Spasm:
Due to secretions Due to irritable airways (smokers)
Rx: 100% Oxygen through face mask Hydrocoritsone 100 mg IV If no improvement rapid intubation to secure the airway
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Post operative Complications

Hypoxemia:
Low FIO2:
Diffusion hypoxemia (N2O 31 times more soluble than O2)

Hypoventilation:
Inadequate N.M. blockade recovery Respiratory depressant effect of volatile agents, narcotics, benzodiazepines Hypocarbia intra operatively Upper abdominal incisions
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Post operative Complications

Increased Right to Left Shunt:
Atelectasis: Inadvertent endobroncial intubation Ateclectasis of the lung Increased Shunt ( R to L ) Blockage of Brochus by blood or mucous plug

Pnemothorax:
following rib injury following CVP placement

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Post operative Complications

Circulatory Complications:
Hypotension:
Decreased preload Decreased myocardial contractility Increased after load

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Post operative Complications

Decreased preload:
Increased blood loss Increased III space loss Un diagnosed urinary loss Septicemia

Decreased myocardial contractility:

Depressant effect of GA drugs Pre-existing ventricular dysfunction Per operative Myocardial infarction

Decreased After load:

Volatile agents depression Septic shock Profound decreased SVR
Septic shock 15 July 2012 Volatile agents effects
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Post operative Complications

Hypertension:
Pain Hypercapnia Hypothermia Hypoxemia Excess Intra vascular volume Pre-existing hypertension

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Post operative Complications

Arrythmias:
Electrolyte imbalance ( K ) Hypoxia Hypercarbia Metabolic acidosis

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Post operative Complications

Post-operative pain & agitation:
Ascertain adequacy of Blood-Gas exchange Evaluate for any gastric or urinary distension Rx: small doses of narcotics.

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Post operative Complications

Nausea & Vomiting:
Frequently seen after
lapraroscopic surgeries Strabismus surgeries

Rx with Ondansetron 4mg IV adults / child 0.1mg/kg Metoclopromide 0.15mg/kg IV

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Post operative Complications

Hypothermia & shivering:
Air-conditioning : excessive cooling Cold IV fluids transfused Cold irrigating fluids used by the surgeon Halothane anaesthesia

Rx by warm blankets Warm IV fluids Inj. Pethidine 10mg IV

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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 recovery room accurately

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Discharge criteria from PACU

All patients must be evaluated by anesthesiologist prior to discharge from PACU Criteria for discharge developed by the Anesthesia department Criteria depends on where the patient is sent ward, ICU, home

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Discharge criteria from PACU

1. 2. 3. 4. Easy arousability Full orientation Ability to maintain & protect airway Stable vital signs for at least 15 30 minutes 5. The ability to call for help if necessary 6. No obvious surgical complication (active bleeding)
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Post-anesthetic Aldrete recovery score

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Interpretation of Modified Aldretes score

Lowest score = 0 2 Score for patient to be shifted to next level of care = 0 to 8
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

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Post-anesthesia discharge scoring system

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Safe guidelines for 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)
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