Fmc postop period

POSTOPERATIVE PERIOD

Romel M. Almoro, M.D., D.P.B.A.Department of AnesthesiaOur Lady of Fatima University

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“The success of a major operation

depends on the intensive postop

care of the patient”

http://student.britannica.com/comptons/article-210788/surgery

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DEFINITION: RecoveryDEFINITION: Recovery

. . .an ongoing process that begins from the end

of intraoperative care until the patient returns to

his/her preoperative physiological state.

Marshall SI, Chung F. Discharge criteria and complications after ambulatory surgery. Anesth Analg 1999; 88: 508–17.

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Early recovery

the discontinuation of anesthetic agents until

recovery of protective reflexes and motor

function -Awad IT and Chung F. Factors affecting recovery and discharge following ambulatory

surgery, Can J Anesth 2006;53:9, 858-72.

PLATINUM 24 HRS AFTER SURGERY when patients are particularly vulnerable and where decision –making is important

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Intermediate recovery

when the patient achieves

criteria for discharge

Late recovery

when the patient returns

to his/her preoperative

physiological state.

Awad IT and Chung F. Factors affecting recovery and discharge following ambulatory surgery, Can J Anesth 2006;53:9, 858-72.

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JOURNEY OF A SURGICAL PATIENT

FACTORS THAT DETERMINE THE NEED FOR POST-OP CARE:

underlying illness

duration and complexity of anesthetic

and surgical procedure

possibility of post-op complications

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ASA STANDARDS FOR POSTANESTHESIA CARE(Approved by the House of Delegates on October 12, 1988 and last amended on October 27, 2004)

STANDARD I

All patients who have received general anesthesia,

regional anesthesia or monitored anesthesia care

shall receive appropriate postanesthesia

management.

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STANDARD II

A patient transported to the PACU shall be accompanied by a

member of the anesthesia care team who is knowledgeable

about the patient’s condition. The patient shall be continually

evaluated and treated during transport with monitoring and

support appropriate to the patient’s condition.

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STANDARD III

Upon arrival in the PACU, the patient shall be re-

evaluated and a verbal report provided to the

responsible PACU nurse by the member of the

anesthesia care team who accompanies the patient.

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STANDARD IV

The patient’s condition shall be evaluated

continually in the PACU.

STANDARD V

A physician is responsible for the discharge of

the patient from the PACU.

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COMPONENTS OF A PACU ADMISSION REPORT

PREOP HISTORY

INTRAOP FACTORS

CURRENT STATUS

POSTOP INSTRUCTIONS

(Mecca RS. Postoperative Recovery. In: Barash PG, Collen BF and Stoelting RK. Clinical Anesthesia

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PR

EO

P H

IST

OR

Y Medication allergies or reaction

Pertinent earlier surgical procedures

Underlying medical illness

Chronic medicationsAcute problems - ischemia, acid-base

status, dehydration

Premedications

NPO status

COMPONENTS OF A PACU ADMISSION REPORT

PREOP HISTORYIntraop FactorsCurrent StatusPostop Instructions

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INT

RA

OP

FA

CT

OR

S Surgical procedure and type of anesthetic

Relaxant/reversal status

Time and amount of opioids

Estimated blood loss and urine output

Unexpected surgical or anesthetic events

Intraop vital signs ranges

Intraop laboratory findings

Drugs givens (steroids, diuretics, antibiotics, vasocative meds)

COMPONENTS OF A PACU ADMISSION REPORT

Preop History

INTRAOP FACTORSCurrent StatusPostop Instructions

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CU

RR

EN

T S

TA

TU

S Airway patency and ventilatory adequacy

LOC, BP, HR and rhythm

ETT position

Intravascular volume status

Functions of invasive monitors

Size and location of IV catheters

Anesthetic equipment (epidural catheter)

Overall impression

COMPONENTS OF A PACU ADMISSION REPORT

Preop HistoryIntraop Factors

CURRENT STATUSPostop Instructions

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PO

ST

OP

IN

ST

RU

CT

ION

S Expected airway and ventilatory status

Acceptable VS ranges

Acceptable urine output and blood loss

Surgical instructions (wound care)

Anticipated CV problems

Orders for therapeutic interventions

Diagnostic tests to be secured

Therapeutic goals and points prior to discharge

Location of responsible physician

COMPONENTS OF A PACU ADMISSION REPORT

Preop HistoryIntraop FactorsCurrent Status

POSTOP INSTRUCTIONS

CARE/MONITORS

oxygenation via face mask

vital signs should be taken every 15 minutes

for the first hour

use of pulse oximeter and single lead

continuous ECG

capnograph or ABG determination for high-

risk patients with compromised ventilatory

functions

DESIGN AND STAFFING

LOCATION AND AREA

near the operating room

with good access to immediate CXR, blood

bank, blood gas and other laboratory

services

DESIGN AND STAFFING

PERSONNEL: Nursing Ratio

1 nurse: 3 patients

1 nurse: 1 critical patient

BEDS

2 RR beds for every 4 procedures in 24 hours

PULMONARY COMPLICATIONS

Airway obstruction

Hypoxemia

Aspiration

Hypoventilation

lead to progressive hypoxemia

PaCO2 : inc. 6 mmHg for the 1st min then 3 – 4 mmHg/min

Over-sedation of patient

AIRWAY OBSTRUCTION

PULMONARY COMPLICATIONS

Airway obstruction

Hypoxemia

Aspiration

Hypoventilation

MANAGEMENT

chin lift maneuver

oral/nasal airway

positive pressure ventilation

with 100% oxygen

succinylcholine with assisted

ventilation

orotracheal intubation

AIRWAY OBSTRUCTION

PULMONARY COMPLICATIONS

Airway obstruction

Hypoxemia

Aspiration

Hypoventilation

ETIOLOGIES:

low inspired concentration of oxygen

increased intra-pulmonary R-L shunt

(most common)

pulmonary edema

pulmonary embolism

post-hyperventilation

diffusion hypoxia

PULMONARY COMPLICATIONS

Airway obstruction

Hypoxemia

Aspiration

Hypoventilation

HYPOXEMIA

ETIOLOGIES:

reduced cardiac output

shivering inc. O2 consumption

500x

type of anesthetic

MONITOR: pulse oximeter

(measures oxygen saturation)

TREATMENT: adequate oxygenation

HYPOXEMIAPULMONARY

COMPLICATIONS Airway obstruction

Hypoxemia

Aspiration

Hypoventilation

ASPIRATION

more common among patients with full stomach

PULMONARY COMPLICATIONS

Airway obstruction

Hypoxemia

Aspiration

Hypoventilation

HYPOVENTILATION

reduced alveolar ventilation result in an increase in

the arterial CO2 due to:

poor respiratory drive

poor muscle function

high production of CO2

presence of acute or chronic lung disease

PULMONARY COMPLICATIONS

Airway obstruction

Hypoxemia

Aspiration

Hypoventilation

CARDIOVASCULAR COMPLICATIONS

Hypotension

Hypertension

Arrhythmia

HYPOTENSION

ETIOLOGIES:

decreased ventricular pre-load

reduced myocardial contractility

reduction in systemic vascular resistance

TREATMENT:

elevation of the legs

crystalloids, colloids and blood

combined inotropic & vasopressor support

CARDIOVASCULAR COMPLICATIONS

Hypotension Hypertension Arrhythmia

HYPERTENSION

ETIOLOGIES:

pain

hypercapnea

excess IVF

pre-existing HPN

CARDIOVASCULAR COMPLICATIONS

Hypotension Hypertension Arrhythmia

ARRHYTHMIA

ETIOLOGIES:

electrolyte imbalance – hypokalemia

hypoxia

hypercapnea

metabolic alkalosis and acidosis

pre-existing heart disease

common arrhythmias: ST, PVC, VT,

SVT (most dangerous) & sinus

bradycardia

CARDIOVASCULAR COMPLICATIONS

Hypotension Hypertension Arrhythmia

RISK FACTORS:

massive transfusion

elderly patients

pre-existing renal disease

major trauma patients

presence of sepsis

surgery on heart and great vessels

biliary surgery (with obstructive jaundice)

PRESENTATION:

oliguria

RENAL COMPLICATIONS

CAUSES:

coagulopathy

loss of vascular integrity

TESTS:

clotting time

prothrombin time (PT)

partial thromboplastim time (PTT)

fibrinogen

platelet count

bleeding time

BLEEDINGCOMPLICATIONS

GOAL:

achieve and maintain plasma level

within the patient’s therapeutic

window since analgesic

requirement is rarely constant

PAIN MANAGEMENT

DRUG CLASSIFICATION

paracetamol

NSAIDs

opioids

local anesthetics

PAIN MANAGEMENT

ROUTES OF

ADMINISTRATION:

oral

rectal

sublingual

epidermal

parenteral: im and iv

neuraxial: epidural and spinal

TRADITIONAL PAIN

MANAGEMENT

fixed doses

fixed intervals

fixed rate infusion

PATIENT-CONTROLLED ANALGESIA (PCA)

PUMP MODES

basal rate mode

PCA mode

combined basal rate and PCA mode

PAIN MANAGEMENT

PATIENT EDUCATION

explain use of PCA pump

establish a trusting relationship with the patient

PCA

Drug concentration: amount of drug in the solution

Loading dose:initial dose prior to basal rate and PCA doses

Lockout Interval:interval after each dose during which demands do not result in another dose being administeredprevents accidental overdose

Basal rate: dose of continuous infusion/hr

PCASetting

PCA Dose:

smaller doses of the drug

also called demand dose

large enough to be effective while minimizing

side effects

One-hour Limit

total amount of drug that can be administered

in one hour

basal rate + PCA doses in 1 hour

PCASetting

VISUAL ANALOG SCALE SCORE

PAIN ASSESSMENT

CATEGORICAL CLASSIFICATIONOF PAIN 0: no pain1 - 3: mild pain4 - 6: moderate 7-10: severe pain

0No pain

10Worst pain

SEDATION ASSESSMENT

measures the patient's responsiveness to his

or her name, quality of speech, degree of

facial relaxation, and ability to focus the eyes.

OBSERVER’S ASSESSMENT OF ALERTNESS & SEDATION (OAAS)

SEDATION ASSESSMENT

OBSERVER’S ASSESSMENT OF ALERTNESS & SEDATION (OAAS)

Does not respond to commands or shaking5

Responds to command only after several attempts and mild prodding

4

Eyes closed. Responds to commands3Slow response and slurred speech2

Awake1DescriptionScore

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Known as the Post Anesthesia Recovery (PAR) Score

Used in the PACU to clinically assess the physicalstatus of patients recovering from the anestheticexperience and to follow their awakening process.

Served as a basis to discharge patients from the PACU toeither the hospital ward or their homes after ambulatorysurgery.

Adopted as the suggested criteria for discharge from the PACU by the Joint Commission of Accreditation of HealthCare Organizations

ALDRETE SCORE

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CRITERIA SCORE

ACTIVITY

Able to move four extremities voluntarily or on command

2

Able to move two extremities voluntarily or on command

1

Unable to move any extremities voluntarily or on command

0

RESPIRATIONAble to breath deeply and cough freely 2Dyspneic or with limited breathing 1Apneic 0

CIRCULATION

BP or HR + or – 20% of pre-anesthetic level

2

BP or HR + or – 21% to 49% of pre-anesthetic level

1

BP or HR + or – 50% of pre-anesthetic level

0

CONSCIOUSNESSFully awake 2Arousable on calling 1Not responding 0

OXYGENSATURATION

Able to maintain O2 saturation > 92% on room air

2

Needs O2 inhalation to maintain O2 saturation > 90%

1

O2 saturation < 90% even with O2 supplement

0

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CRITERIASCORE

PAINPain free 2Mild pain handled by oral meds 1Pain requiring parenteral meds 0

DRESSINGDry 2Wet but stationary 1Wet but growing 0

URNE OUTPUT

Has avoided freely / Adequate output with catheter

2

Unable to void but comfortable / Adequate output but requiring IV fluid maintenance

1

Unable to void and uncomfortable / Oliguric 0

AMBULATIONAble to stand up and walk straight 2Vertigo when erect 1Dizziness when supine 0

FASTING-FEEDING

Able to drink fluids 2Nauseated 1Nausea and vomiting 0

patients may be discharged from the care of the anesthesiologist in the PACU on attaining a Aldrete Score/PARS of 10

GENERAL CONDITION

Oriented to time, place

and surgical procedure

Responds to verbal input

and follows simple

instructions

Acceptable color without

cyanosis, splotchiness

or pallor

DISCHARGE EVALUATION GUIDELINES

General Condition Heart Rate & Rhythm Ventilation & Oxygenation Systemic BP Airway Maintenance Pain Control Renal Function Metabolic or Laboratory Ambulatory Patients

GENERAL CONDITION

Adequate muscular strength

& mobility for minimal self-care

Absence or control of specific

acute surgical complications

(bleeding, edema, neurologic

weakness, diminished pulses)

Suitable control of nausea and

emesis

DISCHARGE EVALUATION GUIDELINES

General Condition Heart Rate & Rhythm Ventilation & Oxygenation Systemic BP Airway Maintenance Pain Control Renal Function Metabolic or Laboratory Ambulatory Patients

HEART RATE & RHYTHM

relatively constant for at

least 30 minutes

resolution of any new

arrhythmias

acceptable intravascular

volume status

any suspicion of MI rectified

DISCHARGE EVALUATION GUIDELINES

General Condition Heart Rate & Rhythm Ventilation & Oxygenation Systemic BP Airway Maintenance Pain Control Renal Function Metabolic or Laboratory Ambulatory Patients

VENTILATION &

OXYGENATION

ventilatory rate > 10 bpm

and < 30 bpm

forced vital capacity

approximately 2x the

tidal volume

adequate ability to cough

and clear secretions

qualitatively acceptable

work of breathing

DISCHARGE EVALUATION GUIDELINES

General Condition Heart Rate & Rhythm Ventilation & Oxygenation Systemic BP Airway Maintenance Pain Control Renal Function Metabolic or Laboratory Ambulatory Patients

SYSTEMIC BP

within +/- 20% of resting pre-

operative value

AIRWAY MAINTENANCE

protective reflexes (e.g.

swallowing, gag) intact

absence of stridor, retraction

or partial obstruction

no further need for artificial

airway support

DISCHARGE EVALUATION GUIDELINES

General Condition Heart Rate & Rhythm Ventilation & Oxygenation Systemic BP Airway Maintenance Pain Control Renal Function Metabolic or Laboratory Ambulatory Patients

PAIN CONTROL

ability to localize and identify

intensity of surgical pain

adequate analgesia at least 15

min since last opioid

safe, appropriate orders for

post-discharge analgesics

DISCHARGE EVALUATION GUIDELINES

General Condition Heart Rate & Rhythm Ventilation & Oxygenation Systemic BP Airway Maintenance Pain Control Renal Function Metabolic or Laboratory Ambulatory Patients

RENAL FUNCTION

urine output > 30 ml/hr

(catheterized patients)

appropriate color and

appearance of urine;

evaluation of hematuria

DISCHARGE EVALUATION GUIDELINES

General Condition Heart Rate & Rhythm Ventilation & Oxygenation Systemic BP Airway Maintenance Pain Control Renal Function Metabolic or Laboratory Ambulatory Patients

METABOLIC OR

LABORATORY

acceptable hematocrit level

in view of hydration, BP &

potential for future losses

suitable control of blood

glucose

appropriate electrolyte

hemostasis

evaluation of CXR, ECG, etc

DISCHARGE EVALUATION GUIDELINES

General Condition Heart Rate & Rhythm Ventilation & Oxygenation Systemic BP Airway Maintenance Pain Control Renal Function Metabolic or Laboratory Ambulatory Patients

AMBULATORY PATIENTS

ability to ambulate without

dizziness, hypotension or

support

suitable control of nausea

& vomiting after ambulation

DISCHARGE EVALUATION GUIDELINES

General Condition Heart Rate & Rhythm Ventilation & Oxygenation Systemic BP Airway Maintenance Pain Control Renal Function Metabolic or Laboratory Ambulatory Patients

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Whenever doubts exist regarding

the ability of patients to recover

safely in unmonitored setting

ADMIT PATIENT TO PACU

Thank you!!!