1. The Recovery Area Dr Paul Townsley ST5 Anaesthesia / Critical Care Nottingham

2. The Recovery Area http://www.rcoa.ac.uk/docs/CCTptii.pdf Chapter 6: Postoperative and Recovery Care

3. AAGBI Guidance AAGBI Website “Publications” http://www.aagbi.org/publications/guidelines

4. Objectives Transfer from Theatre Handover Monitoring + Recovery Room Equipment Criteria for discharge from recovery Daycase Common Post-operative Problems

5. The Transfer from theatre Safety 1st…Safety 2nd Awake / Asleep Airway + OXYGEN o ETT? o LMA in or out? o T - Bag (O2) Breathing CVS Stable ? Monitoring

6. Recovery Room Requirements At least 2 beds per theatre? Minimum of 2 staff at all times Effective Emergency Call system Ventilation - 15 x air changes per hour? Resus Equipment Monitoring

7. The Handover BE PATIENT  QMC space + nurse pre-confirmed  Different elsewhere CLEAR summary  Name / PMH / Op / Anaesthetic / Drugs  Difficulties  Behavior  Post-op instructions Your name / bleep / theatre Be Nice to the Recovery Nurse!!

8. Monitoring in Recovery Minimum - BP / sats Also immediately available: o ECG o Nerve stimulator o Thermometer o Capnograph Sick Patients o full Critical Care monitoring AAGBI Publication

9. Criteria for Discharge from Recovery 1.Fully Conscious + Airway Reflexes 2.Adequate Respiration and Oxygenation 3.CVS Stable  no ongoing bleeding 4.Pain and Emesis controlled  Pain < 4 on VAS (1) 5.Temp > 36 0 C (2) 6.O2 and IV Fluids prescribed References 1.RCOA Audit Recipe Booklet 2.NICE Guidance: Perioperative Hypothermia (Inadvertent)

10. Daycase Discharges Telephone access at home Carer for 24 hrs post discharge

11. ATTITUDES Patience Rapid Response to Calls for Help Review patients When can you go home?

12. Common / Serious Postoperative Problems

13. Case 1 - The Noisy Breather 28 yr old male PMH: Fit + well Anaesthetic Hx and Exam NAD RIH Repair GA with LMA Uneventful Transferred to recovery LMA still in situ, T-Bag

14. Case 1 - The Noisy Breather You are called urgently: sats 85% A  LMA with T-Bag B  RR 20  Occasional high pitched inspiratory noise  See-saw breathing, tracheal recession  Sats now 70% C ? D  Still effectively under GA DIAGNOSIS?

15. Postoperative Stridor Listen to the Noise Upper Airway - like snoring / rattling Lower Airway - high pitched Inspiratory / Expiratory

16. Postoperative Stridor - Laryngospasm Incidence 1% general population 3% kids 10% if recent URTI / Smokers Causes Inadequate depth of Anaesthesia Local Stimulation of Larynx  LMA  Sputum  Blood  Vocal Cord Trauma / Surgery Distal Stimulation  (Brewer-Luckhardt Reflex)

17. Post-operative Stridor - Laryngospasm Treatment 100% O2 Breathing circuit CPAP Deepen Anaesthesia Suxamethonium (25mg - 50mg) (Atropine) HYPOXIA + SUXAMETHONIUM = BRADYCARDIA

18. Case 2: The Noisy Breather stays BLUE Sats remain 90% on 100% O2 A  Talking B  RR 30  Sats 90%  Good chest expansion  Crackles to top of mid zones bilaterally C  Pulse 100 reg  BP 130/80 DIFFERENTIAL?

19. Case 2: BLUE Noisy Breather’s CXR DIAGNOSIS? Insert Pic of Pulmonary Oedema

20. Negative Pressure Pulmonary Oedema CAUSE: Upper airway obstruction  Biting on tube  Laryngospasm  Pharyngeal obstruction Huge Negative Intrathoracic Pressures

21. Negative Pressure Pulmonary Oedema TREATMENT: ABC Oxygen Frusemide CPAP HDU Can take days to improve

22. Case 3: The Jittery Blue Bloke 60yr male PMH: Asthma, BP, Umbilical Hernia Repair GA: Propofol, Rocuronium, Fentanyl, LA ETT Uneventful surgery Extubated and T/F to recovery

23. Case 3: The Jittery Blue bloke On arrival in Recovery: sats 90% A  Making incomprehensible noises. Looks SOB B  RR 35  Shallow breaths  Chest clear on asucultation  Sats 90% on 100% O2 C  Pulse 130  BP 200/110 D  Eyes open, Obeying commands, Looks jittery DIFFERENTIAL?

24. Case 3: The Jittery Blue Bloke Further Examination: Able to hold head off the pillow for 2 seconds only C-Circuit with 2 Litre Bag - approx V T 150mls DIAGNOSIS?

25. Inadequate Reversal of NMB Symptoms Hypoxia Airway obstruction Poor resp effort Poor cough - risk of aspiration Signs Jittery Weakness tests  Head off pillow > 5 seconds  Hold arm in air > 5 seconds

26. Inadequate Reversal of NMB Management Prevention:  Nerve Stimulator  ? All patients receiving NDMR should have reversal? ABC Treatment  GA  Neostigmine  Dose = 50-70mcg/kg = 3.5mg for 70kg person  Vial = 2.5mg  ? Sugammadex

27. Postoperative Shivering Cause  Temperature often normal  ?Anaesthetic Agents block descending inhibition of spinal reflexes  GA / Epidural / ?Spinal Physiological Effects  Upto 6 x increase metabolic rate  Upto 3 x Increase O2 consumption Management  ABC  Oxygen  Check Temperature - +/- warming  Pethidine 25mg iv

29. Reminder of References AAGBI Website RCOA Website