Beyond the OR; Recovery Room Catherine Barnes Education Consultant STVMPH 2007

What is PACU A highly skilled area that provides close monitoring and care of all patients emerging from ANY anaesthetic Recovery from anaesthesia is usually uneventful but complications can be sudden and even life threatening Catherine Barnes, 2007

The Process; What to do Handover Assessment Maintenance Discharge Primary Secondary Maintenance Discharge Do it all again/Coffee break Catherine Barnes, 2007

Handover Hand-over from anaesthetist includes: Pt name and age History Medical & surgical Operation (today) type of anaesthetic & drugs given vital signs intra-op specific orders (analgesia, IV, care, obs) blood loss - dressing/drains significant events Catherine Barnes, 2007

At the start; Ratios Ratio: Close and vigilant monitoring is essential 1:2-4 for routine patients 1:1 for high acuity patients paediatrics intra-op complications significant pre-existing medical problems intubated patient Close and vigilant monitoring is essential Catherine Barnes, 2007

Initial Assessment DRABCDE Danger Response Airway Breathing Circulation Dressing/Drains Extras Catherine Barnes, 2007

Airway ASSESS Patent Rate and depth Monitor SpO2 Pt colour Self maintained Device Rate and depth Observe chest movement ‘work of breath’ Monitor SpO2 Pt colour Auscultate (any adventitious or normal sounds?) Encourage DB&C Catherine Barnes, 2007

Airway Devices Guedel's Nasopharyngeal LMA ETT Catherine Barnes, 2007

Removing an artificial airway IF ARTIFICIAL AIRWAY INSITU - A REGISTERED NURSE MUST REMAIN WITH PATIENT AT ALL TIMES An airway can be removed once the patient regains consciousness and can maintain own patent airway Catherine Barnes, 2007

Guedel airway Removal Do not leave patient Administer O2 Hudson mask Continue O2 therapy and airway observations Remove once patient is responsive Catherine Barnes, 2007

LMA Removal Do NOT leave patient, continuously observe airway Continue O2 at 6-10 L/min Deeply anaesthetised or awake to prevent laryngospasm from occurring Catherine Barnes, 2007

Removal of Endotracheal Tubes (ETT) 1:1 nursing Never left under any circumstances Should be removed by the anaesthetist following extubation pt should receive oxygen via Hudson mask there are hospitals that are equipped for intubated patients in PACU Catherine Barnes, 2007

Cardiovascular Assessment Monitor continuously & document 10 minutely (5 min if unconscious) HR Rhythm where monitored BP NIBP Arterial Catherine Barnes, 2007

Respiratory Assessment Usually with airway & breathing How effective Any additional therapy required? WOB Residual MR Underlying medical condition Post op complication FiO2 & SpO2 with all other observations Catherine Barnes, 2007

Neurological Assessment Preoperatively Anaesthetic nurses should always check neuro assessment with the ward nurses Glasgow Coma Scale assesses overall functional state of brain Neuro assessment consists of 4 components: Coma scale Pupil size and reaction to light (CN III) Limb responses Vital signs Catherine Barnes, 2007

Neurovascular Assessment Different to Neurological Check for; colour - is it pink or pale? warmth - is it cool or hot to touch? sensation - pins & needles? Feels normal movement - free movement Always check that a pre-operative neurovascular assessment has been done and documented, Why do we need to check this? Catherine Barnes, 2007

Pain; Oh No (Ouch) If not done correctly & appropriately Pain assessment & management are one of the biggest challenges for the PACU nurse There are many definitions “pain is what the patient says it is when ever it occurs” Evaluate by using pain score commence analgesia as ordered pain modalities include: intermittent I.V. narcotic IM, oral or rectal IV narcotic infusions PCA local & regional nerve blocks epidural Notify Anaesthetist is pain unrelieved Ensure post-op analgesia orders are given Ensure narcotics are clearly labelled document all narcotic, PCA and epidural infusions on pain observation chart document any analgesia given Adjunctive therapies include; positioning, aromatherapy, relaxation/massage Catherine Barnes, 2007 Catherine Barnes, 2007

Other Assessment Observe and document wound site & drains Fluid status; check FBC check urine output ensure IV orders are given, IV to remain in check all drain tubes and document IV burette All flasks 8/24 and longer Paediatrics Catherine Barnes, 2007

Other things to remember Reassure patient Explain to patient where they are, how long they are staying and any procedures you carry out As a rule do not discuss surgery (leave this to surgeon) maintain privacy and encourage continuity of care Patient safety & comfort Ensure patient safety at all times cot sides up bed linen dry elevate limbs as ordered assess patient skin integrity and pressure areas maintain normothermia Catherine Barnes, 2007 Catherine Barnes, 2007

Documentation “Remember if it is not documented it is considered NOT done” Ensure all documentation is complete and signed prior to pt discharge post operative record anaesthetic record treatment sheet fluid orders & drug chart specific obs chart post operative checklist/clinical pathway checklist Catherine Barnes, 2007

Discharge Pts must meet the following criteria prior to discharge; conscious & co-operative maintain adequate ventilation and own airway comfortable pain under control nausea absent or minimal dressing dry & secure acceptable drainage levels Haemodynamically stable (20% preop values) Normothermic (greater 35.5) Each hospital has different criteria; STVMPH new Catherine Barnes, 2007

Complications Post operative respiratory insufficiency is one of the most commonly encountered complications in the recovery room for both healthy and unhealthy patients. No one is an exception Airway Upper Lower Hypotension Hypertension Hypothermia Catherine Barnes, 2007 Catherine Barnes, 2007

What & when The most common airway complications you will encounter in PACU are; airway obstruction laryngospasm bronchospam Catherine Barnes, 2007

Upper airway obstruction The most common form of airway obstruction in the PACU Is the tongue on the posterior pharyngeal wall. Laryngeal obstructions are most associated with endotracheal tubes, laryngeal spasm or soiling of the resp tract with vomit secretions or blood. Catherine Barnes, 2007

Management Can either be invasive or non-invasive non invasive Position jaw support head tilt Invasive Suctioning oro/nasopharyngeal airway L.M.A Catherine Barnes, 2007

Laryngospasm Laryngeal spasm is a forceful involuntary spasm of the laryngeal musculature caused by sensory stimulation of the superior laryngeal nerve. It is an upper airway obstruction. Caused by sudden violent contraction of the vocal cords. May be complete or partial obstruction PRECIPITATING FACTORS Anxiety. Early insertion of airway or scope blade. Stimulation of cords by secretions, foreign bodies, etc. Vocal trauma. Painful stimulus in the lightly anaesthetised patient Inhalation of chemical irritants. After extubation. URTI. Movement of patient. Light levels of anaesthesia. Catherine Barnes, 2007 Catherine Barnes, 2007

S&S PARTIAL OBSTRUCTION Inspiring stridor. High pitch crowing sound on inspiration. Upper airway noise on auscultation. Increased inspiratory effort. Tracheal tug. Paradoxical chest and abdominal movement. Decreased chest excursion. Beware of regurgitation and aspiration Catherine Barnes, 2007

S&S COMPLETE No audible sounds. Breath sounds absent. Inability to ventilate THIS IS AN AIRWAY EMERGENCY Catherine Barnes, 2007

Lower Airway Obstruction Most common of these is bronchospasm. It may occur in response to a specific inhalational anaesthetic, painful stimulus at a light plane of anaesthesia or in response to soiling of the respiratory tract. Incorrect placement of the ETT Anaphylaxis Bronchospasm is a reflex contraction of bronchial smooth muscle in response to a wide variety of stimuli causing constriction Catherine Barnes, 2007

S&S Respiratory distress and dyspnoea Coughing and tightness in chest Expiratory wheeze (auscultate) Mild prolonged expiration Increased circuit pressure, inability to ventilate Reduction in tidal volumes Rising ETCO2 Sudden decrease in SpO2 Skin colour pale, cyanosis AT RISK PATIENTS Asthma COAD Smokers Patients with pre-existing disease Pulmonary fibrosis Pneumonitis Catherine Barnes, 2007 Catherine Barnes, 2007

Prevention Identify patients at risk Smooth induction Ensure ETT is positioned correctly Ensure patient is deeply anaesthetised prior to surgical stimulation Catherine Barnes, 2007

Emergency Management Management will depend on severity Remove stimulus Increase oxygenation 100% IPPV Withdraw ETT a few cms Check if ETT is blocked, if so, change it Deepen anaesthesia Catherine Barnes, 2007

Management Good airway management during anaesthesia and in the PACU is reliant upon assessment and early intervention . Extensive knowledge of anaesthesia and advanced physiology are essential. Catherine Barnes, 2007

Finally, one last word These are just a few of the many complications you may encounter in PACU Just always remain vigilant and always ask another PACU member if you are not sure The more you know the more you realise how things can go wrong!!! Catherine Barnes, 2007