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

2. 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

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

4. 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

5. 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

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

7. 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

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

9. 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

10. 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

11. 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

12. 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

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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

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

24. 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

25. 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

26. 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

27. 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

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

29. 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

30. 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

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

32. 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

33. 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

34. 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