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بسم الله الرحمن الرحيم
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Postoperative care - Post Anesthesia Care Unit “PACU”
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PACU Design should match function Location: Monitoring equipment
Close to the operating suite. Access to x-ray, blood bank & clinical labs. Monitoring equipment Emergency equipment Personnel
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Admission to PACU Coordinate prior to arrival, Assess airway,
Administer oxygen, Apply monitors, Obtain vital signs, Receive report from anesthesia personnel.
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PACU - ASA Standards Standard I Standard II Standard III Standard IV
All patients should receive appropriate care Standard II All patients will be accompanied by one of anesthesia team Standard III The patient will be reevaluated & report given to the nurse Standard IV The patient shall be continually monitored in the PACU Standard V A physician will signing for the patient out of the PACU
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Patient Care in the PACU
Admission Apply oxygen and monitor Receive report Monitor & Observe & Manage To Achieve Cardiovascular stability Respiratory stability Pain control Discharge from PACU
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Monitoring in the PACU Baseline vital signs. Respiration Circulation
RR/min, Rythm Pulse oximetry Circulation PR/min & Blood pressure ECG Level of consciousness Pain scores
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Initial Assessment Color Respiration Circulation Consciousness
Activity
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Aldrete Score 2 1 Score Activity Respiration Circulation
Consciousness Oxygen Saturation 2 Moves all extremities Breaths deeply and coughs freely. BP + 20 mm of preanesth. level Fully awake Spo2 > 92% on room air 1 Moves 2 extremities Dyspneic, or shallow breathing BP mm of preanesth. level Arousable on calling Spo2 >90% With suppl. O2 Unable to move extremities Apneic BP + 50 mm of preanesth. level Not responding Spo2 <92%
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Common PACU Problems Airway obstruction Hypoxemia Hypoventilation
Hypotension Hypertension Cardiac dysrhythmias Hypothermia Bleeding Agitation Delayed recovery “PONV” Pain Oliguria
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Airway Obstruction Most common tongue in posterior pharynx
May be foreign body Inadequate relaxant reversal Residual anesthesia
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Management of Airway Obstruction
Patient’s stimulation, Suction, Oral Airway, Nasal Airway, Others: Tracheal intubation Cricothyroidotomy Tracheotomy
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Hypoventilation Residual anesthesia Post oper - Analgesia Narcotics
Inhalation agent Residual Relaxant Post oper - Analgesia Intravenous Epidural
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Hypoventilation Treatment
Close observation, Assess the problem, Treatment of the cause: Reverse relaxant Reverse narcotic Reverse midazolam
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Hypertension Common causes: e.g. Hypertensive patients Fluid overload
Pain Full Bladder Hypertensive patients Fluid overload Excessive use of vasopressors
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Hypertension Treatment
Effective pain control Sedation Anti-hypertensives: Beta blockers Alpha blockers Hydralazine (Apresoline) Calcium channel blockers
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Hypotension Decreased venous return Hypovolemia, Sympathectomy,
fluid intake losses Bleeding Sympathectomy, 3rd space loss, Left ventricular dysfunction
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Treatment of Hypotension
Initially treat with fluid bolus, + Vasopressors, + Correction of the cause
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Dysrhythmias Secondary to hypoxemia hypercarbia Acidosis
Catecholamines Electrolyte abnormalities Hypothermia
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Dysrhythmia Treatment
Identify and treat the cause, Assure oxygenation, Pharmacological
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Urine Output Oliguria Treatment: Hypovolemia, Surgical trauma,
Impaired renal function, Mechanical blocking of catheter. Treatment: Assess catheter patency Fluid bolus Diuretics e.g. Lasix
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Post op Bleeding Causes: Treatment: Usually surgical problem
Coagulopathy Treatment: Start i.v. lines push fluids Blood sample, Cross matching, CBC, Notify the surgeon, Correction of the cause
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Hypothermia Most of patients will arrive cold Treatment:
Get baseline temperature Actively rewarm Administer oxygen if shivering Take care for: Pediatric, Geriatric.
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Altered Mental Status Reaction to drugs? Pain Full bladder
Drugs e.g. sedatives, anticholinergics Intoxication / Drug abusers Pain Full bladder Hypoventilation Low COP CVA
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Treatment of Altered Mental Status
Reassurances, Always protect the patient, Evaluate the cause, Treatment of symptoms, Sedatives / Opioids if necessary.
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Delayed Recovery Systematic evaluation Pre-op status
Intraoperative events Ventilation Response to Stimulation Cardiovascular status
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Delayed Recovery The most common cause: Hypothermia,
Residual anesthesia Consider reversal Hypothermia, Metabolic e.g. diabetic coma, Underlying psychiatric problem CVA
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Postoperative Nausea & Vomiting “PONV”
Risk factors Type & duration of surgery, Type of anesthesia, Drugs, Hormone levels, Medical problems, Autonomic involvement.
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Prevention of PONV NPO status Droperidol, Metoclopramide, H2 blockers,
Ondansetron, Acupuncture
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WHO Algorithm for Management of Pain
+ Multidisciplinary: Adjuvant therapy. Psychotherapy. Physioltherapy. Causal diag. & ttt. + Adjuvant therapy WHO III Strong opioids + Adjuvant therapy WHO class II Weak opioids + Adjuvant therapy WHO class I PNSAIDs
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Regional Blocks Local infiltration Peripheral nerve blocks
Plexus block: UL: Brachial PB LL: Lumbar PB Thoracic: Intercostal, Interpleural, Paravertebral Epidural: Thoracic Lumbar Caudal
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PACU Discharge Criteria
Fully Awake, Patent airway, Good respiratory function, Stable vital signs, Patency of tubes, catheters, IV’s Pain free, Reassurance of surgical site.
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Postanesthesia Discharge Scoring System
Vital Signs (PR & ABP) Activity PONV Pain Surgical Bleeding 2: Within 20% of preoperative baseline 2: Steady gait, no dizziness 2: Minimal: treat with PO meds 2: Acceptable control per the patient; controlled with PO meds 2: Minimal: no dressing changes required 1: % of preoperative baseline 1: Requires assistance 1: Moderate: treat with IM medications 1: Not acceptable to the patient; not controlled with PO medications 1: Moderate: up to 2 dressing changes 0: >40% of preoperative baseline 0: Unable to ambulate 0: Continues: repeated treatment 0: Severe: more than 3 dressing changes
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Post-operative Care “PACU”
Thank You
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