32: Postanesthetic Care

CHAPTER 32 Postanesthetic Care



Michael M. Sawyer, MD



1 Which patients should be cared for in the postanesthetic care unit?


Postanesthetic care unit (PACU) care is traditionally divided into phase 1, during which monitoring and staffing ratios are equivalent to an intensive care unit, and phase 2, wherein transition is made from intensive observation to preparation for care on a surgical ward or at home.


Fast-track recovery is emerging because of fast-offset anesthetic agents and adjunctive drugs. Most patients who have had monitoring plus sedation or extremity regional anesthesia should be appropriate for fast track recovery, bypassing phase 1. Typically, however, after inhalation general anesthesia or neuraxis regional anesthesia, a period of phase 1 care is required. Coexisting disease, the surgical procedure, and pharmacologic implications of the anesthetic agents used ultimately determine the most appropriate sequence of postoperative care for each patient.



2 Review important considerations as the patient is about to be moved from the operating room to the postanesthetic care unit


Transport from the operating room (OR) to the PACU can be a dangerous time for patients. Recent PACU designs have been developed to make this trip as short as possible. However, many institutions still are burdened with PACUs remote from the ORs. This has also become an issue with the development of many newer satellite locations where anesthetics are performed (e.g., magnetic resonance imaging). Before transport a patient should be able to maintain a patent airway with spontaneous respirations. The use of supplemental oxygen for transport is recommended. More complicated patients require the use of a transport monitor to facilitate close assessment.



3 Describe the process for postanesthetic care unit admission


A report is given by the anesthesia caregiver to the PACU nurse, reviewing the patient’s prior health status, surgical procedure, intraoperative events, agents used, and anesthetic course. The use of muscle relaxants and reversal of neuromuscular blockade, the intraoperative interventions for analgesia, and the intraoperative fluids and blood products received guide in planning PACU care. Initial assessment of the patient by the PACU nurse includes vital signs, baseline responsiveness, adequacy of ventilation, and adequacy of analgesia. Various scoring systems have been used to allow numeric scoring of subjective observations as an indicator of progress toward discharge. The Aldrete scoring system (Table 32-1) tracks five observations: activity, respiratory effort, circulation, consciousness, and oxygenation. Scales for each are 0 to 2, and a total score of 8 to 10 indicates readiness to move to the next phase of care. Regression of motor block in the case of regional anesthesia is also an important determinant of readiness for discharge.


TABLE 32-1 The Aldrete Score























Activity
Able to move four extremities

Able to move two extremities

Not able to move extremities voluntarily or on command
2

1

0
Respiration
Able to breathe and cough

Dyspnea or limited breathing

Apneic
2

1

0
Circulation
BP ± 20% of preanesthetic level

BP ± 21%-49% of preanesthetic level

BP ± 50% of preanesthetic level
2

1

0
Consciousness
Fully awake

Arousable on calling

Not responding
2

1

0
O2 saturation
Maintain O2 saturation >92% in room air

Needs O2 to maintain O2 saturation >90%

O2 saturation <90% with O2 supplement
2

1

0

BP, Blood pressure.


Adapted from Aldrete AJ, Krovlik D: The postanesthetic recovery score, Anesth Analg 49:924–933, 1970.



4 What monitors should be used routinely in the postanesthetic care unit?


The level of care will depend on the clinical status of the patient. Pulse oximetry and periodic blood pressure monitoring should be used routinely on all patients. Interestingly, routine electrocardiogram (ECG) monitoring has not been found to be of value in patients without risk factors of coronary disease. Finally temperature, urine output, and surgical drainage require monitoring as appropriate.



5 What problems should be resolved during postanesthetic care?



image Hypoventilation: The patient should be breathing easily and able to cough on command and oxygenate to near preanesthetic levels.

image Hemodynamic stability: Blood pressure should be within 20% of preanesthetic measurements with stable heart rate and rhythm.

image Attenuated sensorium: The patient should be fully awake and voluntarily move all extremities.

image Postoperative pain: Pain management should no longer require continuous nursing intervention.

image Postoperative nausea and vomiting (PONV): PONV should be treated aggressively since it is associated with prolonged length of stay in the PACU and decreased patient satisfaction with the perioperative experience.


6 How is ventilation adversely affected by anesthesia?


Residual neuromuscular blockade, opioid effects, and lingering effects of inhalational anesthesia can result in postoperative hypoventilation (Table 32-2).


TABLE 32-2 Ventilation Problems in the Postanesthetic Care Unit





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May 31, 2016 | Posted by in ANESTHESIA | Comments Off on 32: Postanesthetic Care

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