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POSTOPERATIVE PERIOD
Romel M. Almoro, M.D., D.P.B.A.Department of AnesthesiaOur Lady of Fatima University
2
“The success of a major operation
depends on the intensive postop
care of the patient”
http://student.britannica.com/comptons/article-210788/surgery
3
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.
4
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
5
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.
6
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
8
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.
9
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.
10
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.
11
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.
12
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
13
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
14
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
15
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
16
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
42
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
43
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
44
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
54
Whenever doubts exist regarding
the ability of patients to recover
safely in unmonitored setting
ADMIT PATIENT TO PACU
Thank you!!!