DR.

AFTAB
 Introduction
 Recovery from general anesthesia is a time of great
physiological stress for many patients.
 Emergence from general anaesthesia should ideally be
smooth and gradual awakening in a control
environment.
 It often begins in the operating room or during
transport to the recovery room and frequently
characterized by complications.
 Even patients receiving spinal or epidural anaesthesia
can experience marked decrease in blood pressure
during transport.
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 The Standards for Postanesthesia Care
I. All patients who have received general anesthesia,
regional anesthesia or monitored anesthesia care shall
receive appropriate post anesthesia management.
II. A patient transported to the PACU shall be
accompanied by a member of the anesthesia care team
who is knowledgeable about the patient's condition.
The patient shall be continually evaluated and treated
during transport with monitoring and support appropriate
to the patient's condition.

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III. Upon arrival in the PACU, the patient shall be re-
evaluated and a verbal report provided to the
responsible PACU nurse by the anesthesia care team
who accompanies the patient.
IV. The patient's condition shall be evaluated
continually in the PACU. The patient shall be observed
and monitored by methods appropriate to the
patient's medical condition.
 Particular attention should be given to monitoring oxygenation,
ventilation, circulation, level of consciousness and temperature.
V. Anaesthesiologist is responsible for the discharge of
the patient from the postanesthesia care unit

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History of the PACU
 Methods of anesthesia have been available for more than
160 years, the PACU has only been common for the past
50 years.
 1920’s and 30’s: several PACU’s opened in the US and
abroad.
 It was not until after WW II that the number of PACU’s
increased significantly. This was do to the shortage of
nurses in the US.
 In 1947 a study was released which showed that over an 11
year period, nearly half of the deaths that occurred
during the first 24 hours after surgery were preventable.
 1949: having a PACU was considered a standard of care.

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PACU Staffing
 One nurse to one patient for the first 15 minutes of
recovery.
 Then one nurse for every two patients.
 The anesthesiologist responsible for managing the
patient in the PACU.

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PACU Location
 Should be located close to the operating suite.
 Immediate access to x-ray, blood bank, blood gas and
clinical labs.
 Should have 1.5 PACU beds per operating room used.
 An open ward is optimal for patient observation, with at
least one isolation room.
 Central nursing station.
 Piped in oxygen, air, and vacuum for suction.
 Requires good ventilation.

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PACU in ideal set up

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 PACU Equipments
 Automated BP, pulse ox, EKG, and intravenous
supports should be located at each bed.
 Area for charting, bed-side supply storage, suction,
and oxygen flow meter at each bed-side.
 Capability for arterial and CVP monitoring.
 Supply of immediately available emergency
equipment. Crash cart. Defibrillator.

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Admission Report
 Preoperative history
 Intra-operative factors :
 Procedure
 Type of anesthesia
 U/O
 Assessment and report of current status
 Post-operative instructions

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ROUTINE RECOVERY
General Anesthesia
 Airway patency, vital signs, and oxygenation should be
checked immediately on arrival.
 Subsequent B.P, P.R , and R.R measurements are
routinely made at least every 5 min for 15 min or until
stable, and every 15 min thereafter.
 Pulse oximetry should be monitored continuously in
all patients recovering from general anesthesia, until
they regain consciousness.

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 Neuromuscular function should be assessed clinically,
eg, head-lift.
 At least one temperature measurement should also be
obtained.
 Additional monitoring includes pain assessment (eg,
numerical or descriptive scales), the presence or
absence of nausea or vomiting, and fluid input and
output including urine flow, drainage, and bleeding.

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 All patients recovering from general anesthesia should
receive 30–40% oxygen during emergence because
transient hypoxemia can develop even in healthy
patients.
 Patients at increased risk for hypoxemia, should
continue to be monitored with a pulse oximeter even
after emergence and may need oxygen
supplementation for longer periods.
 Arterial blood gas measurements can be obtained to
confirm abnormal oximetry readings.

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 Oxygen therapy should be controlled in patients of
COPD or history of CO2 retention.

 Patients should generally be nursed in the head-up

position whenever possible to optimize oxygenation.

 Deep breathing and coughing should be encouraged

periodically.

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 Regional Anesthesia
 Pt. heavily sedated or hemodynamically unstable
following regional anesthesia should also receive
supplemental oxygen in the PACU.
 Sensory and motor levels should be periodically
recorded following regional anesthesia
 Precautions in the form of padding or repeated
warning may be necessary to prevent self-injury from
uncoordinated arm movements following brachial
plexus blocks.

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 Blood pressure should be closely monitored following
spinal and epidural anesthesia.

 Bladder catheterization may be necessary in patients

who have had spinal or epidural anesthesia for longer
than 4 h.

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Post op Complications
1. Pain
2. PONV
3. Delirium & emergence excitement
4. Shivering & hypothermia
5. Respiratory complications
6. Circulatory complications
7. Renal dysfunction

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(1)Pain
 Post-operative pain management should be an
essential and integral part of the care given to the
patient.

 A ‘major postoperative pain” is defined as the pain that

could endanger life if inadequately relieved, and for
which more vigorous and effectives treatments may be
justified although carrying risk.

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 In day care surgery, inadequate treatment of pain from
a relatively trivial insult may cause an unplanned
hospital admission.

 In hand surgery, inadequate treatment of pain may

hinder mobilization function.

 After Caesarean section, a mother’s pain may prejudice

the bonding with her newborn child.

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Postoperative pain management options
1)Cognitive behavioral interventions: such as relaxation,
distraction, ; these can be taught preoperatively & can
reduce pain, anxiety, & the amount of drugs needed for
pain control.
2)Systemic administration of nonsteroidal anti-
inflammatory drugs (NSAIDs) or opioids using the
traditional ‘as needed’ schedule or around-the-clock
administration
3)Patient controlled analgesia (PCA), usually meaning
self-medication with intravenous doses of an opioid; this
can include other classes of drugs administered orally or by
other routes.

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4)Spinal or Epidural analgesia, usually by means of an
epidural opioid and/or local anaesthetic injected
intermittently or infused continuously.
5)Intermittent or continuous local neural blockade
(examples of the former include intercostal nerve blockade
with local anaesthetic or cryoprobe; the latter includes
infusion of local anaesthetic through an interpleural
catheter)
6) Physical agents such as massage or application of
heat or cold.
7)Electroanalgesia such as transcutaneous electrical
nerve stimulation (TENS)

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Intravenous Patient-Controlled
Analgesia
 Intravenous patient-controlled analgesia (PCA)
optimizes delivery of analgesic opioids and minimizes
the effects of pharmacokinetic and pharmacodynamic
variability in individual patients.

 A PCA device can be programmed for several variables,

including the demand (bolus) dose, lockout interval,
and background infusion.

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 A lockout interval that is too long may result in
inadequate analgesia and decrease the effectiveness
of intravenous PCA.

 Too short Lockout Interval-Repeated dosing-

Undesirable side effect.

 most intervals range from 5 to 10 minutes,

depending on the medication in the PCA pump.

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Intravenous patient controlled anaesthesia dose regimen

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Ketamine
 Traditionally recognized as an intraoperative
anesthetic agent
 Its used for postoperative analgesia has increased
because of its NMDA-antagonistic properties, which
may be important in attenuating central sensitization
and opioid tolerance.
 Perioperative ketamine reduced 24-hour PCA
morphine consumption and postoperative nausea or
vomiting and had minimal adverse effects.

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Regional Analgesic Techniques
 Neuraxial (primarily epidural) and peripheral regional
analgesic techniques may be used for the effective
treatment of postoperative pain.
 In general, the analgesia provided by epidural and
peripheral techniques (particularly when local
anesthetics are used) is superior to that with systemic
opioids.
 use of these techniques may even reduce morbidity
and mortality.

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Properties of neuraxial opoids

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Doses of neuraxial opoids

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Patient-Controlled Epidural Analgesia
 PCEA is a safe and effective technique for
postoperative analgesia on routine surgical wards.
 Like intravenous PCA, PCEA allows individualization
of postoperative analgesic requirements and may have
several advantages over CEI.
 Background infusion in addition to the demand dose
is more common with PCEA than with intravenous
PCA .

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Patient-controlled Epidural Analgesia Regimens

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Peripheral Regional Analgesia
 Peripheral regional analgesic techniques as a single
injection or continuous infusion can provide analgesia
superior to that with systemic opioids.

 Wound infiltration and peripheral regional techniques

(e.g., brachial plexus, lumbar plexus, femoral, sciatic-
popliteal, and scalp nerve blocks) can be used to
enhance postoperative analgesia.

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 (2)Nausea & Vomiting
 Postoperative nausea and vomiting (PONV) are a
common problem following general anesthesia,
occurring in 20–30% of all patients.
 Moreover, PONV may occur only at home within 24 hr
of an uneventful discharge (postdischarge nausea and
vomiting) in a significant number of additional
patients.
 From a patients perspective PONV can be more
problematic than postoperative pain.

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 Risk factors for PONV
Patients factor Anaesthetic techniques
 Young age  General anaesthesia
 Female gender  Opioids
 Large body habitus  Volatile anesthetics
 History of prior PONV
 History of motion sickness

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Surgical factor Postoperative factor
 Strabismus surgery  Postopertive pain
 Laproscopic surgery  Hypotension
 Ear surgery
 Orchidopexy
 Gynaecological surgeries
 Tonsillectomy

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Commonly used antiemetic drugs

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(3)Delirium
 Approximately 10% of adult patients over the age of 50
who undergo elective surgery will experience some
degree of postoperative delirium within the first 5
postoperative days.
The most significant preoperative risk factors include
 advancing age (>70 years)
 preoperative cognitive impairment,
 decreased functional status
 alcohol abuse
 a previous history of delirium.

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Intraoperative factors that are predictive of postoperative
delirium include

 1.)surgical blood loss

 2.) hematocrit less than 30%

 3.)number of intraoperative blood transfusions.

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Management of delirium

 High risk patient should be identified before admission to

PACU.
 Severely agitated patients require restraints or additional
personnel to avoid self-inflicted injury.
 Elderly patients who are to undergo minor surgery should
be scheduled in an outpatient center.
 It minimize the incidence of post op delirium.

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 Emergence Excitement

 A transient confusional state that is associated with

emergence from general anesthesia.
 Should be differentiated from persistent postoperative
delirium.
 Common in children, with more than 30%
experiencing agitation or delirium.
 Usually occurs within the first 10 minutes of recovery
but can have onset later in children who are brought to
the recovery room asleep.

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 The peak age of emergence excitement in children is
between 2 and 4 years.

 In children, emergence excitement is most frequently

associated with rapid “wake up” from inhalational
anesthesia.

 most often associated with sevoflurane and

desflurane.

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 Preventative measures are reducing preoperative
anxiety, treating postoperative pain, and providing a
stress-free environment for recovery.

 Medications that have been used to prevent and treat

emergence agitation/delirium in children include
midazolam, clonidine, dexmedetomidine, fentanyl,
ketorolac, and physostigmine.

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(4)Shivering & Hypothermia
 Can occur due to intra op hypothermia or side effect of
anaesthetic agents.
 Most important cause –redistribution of heat –core to
peripheral compartment.
 Cool ambient temperature .
 Use of cold I.V fluids.
 Incidence related to duration of surgery and use of
volatile anaesthetic agents.

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Management
 Forced air warming device.

 Exclude cause such as bacteremia , sepsis ,allergy or

transfusion rxn.

 Meperidine (10-25 mg) also shown to reduce shivering.

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(5)Respiratory complications
 Most frequently encountered serious complications in
the PACU.
 Majority are related to
1. airway obstruction
2. hypoventilation
3. hypoxemia.

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 Upper Airway Obstruction
Loss of Pharyngeal Muscle Tone
 Most frequent cause of airway obstruction in the
immediate postoperative period.
 Characterized by a paradoxical breathing pattern.
 Can be relieved by “jaw thrust maneuver” or
continuous positive airway pressure (CPAP) applied via
facemask (or both).
 In selected patients, placement of an oral or nasal
airway, laryngeal mask airway, or endotracheal tube
may be required.
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Residual neuromuscular blockade
 Residual NM blockade is an important cause of airway
obstruction in PACU.
 Pharyngeal function is not restored fully below a train of
four ratio of 0.9
 Clinically 5 second sustained head lift is a good indicator.
(other signs grip strength, tongue protrusion, the
ability to lift the legs off the bed)
 Ability to strongly appose incisor teeth against a tongue
depressor is a best sign. This maneuver correlates with
an average train-of-four ratio of 0.85 as opposed to
0.60 for the sustained head lift.

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Factors contributing to a prolonged NDMR block

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Factors contributing to prolonged DMR blockade

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 Laryngospasm
 Sudden spasm of the vocal cords that completely
occludes the laryngeal opening.

 Typically occurs in the transitional period when the

extubated patient is emerging from general anesthesia.

 Patients who arrive in the PACU asleep after general

anesthesia are also at risk for laryngospasm on
awakening.

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 Chest wall retraction
 High pitch inspiratory stridor
 Decreased breath sound
 Hypoxemia

 Jaw thrust with CPAP (up to 40 cm H2O) is often

sufficient stimulation to “break” the laryngospasm.

 Skeletal muscle relaxation can be achieved with

succinylcholine (0.1 to 1.0 mg/kg IV or 4 mg/kg IM).

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 Edema or Hematoma
 Possible operative complication in patients
undergoing prolonged procedures in the prone or
Trendelenburg position.
 Surgical procedures on the tongue, pharynx, and neck,
including thyroidectomy, carotid endarterectomy,
and cervical spine procedures, can produce more
localized tissue edema or hematoma.

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Evaluation of airway for tracheal extubation
1) After deflating the endotracheal tube cuff proximal end of
the endotracheal tube is occluded
. Patient is then asked to breathe around the tube.
. Good air movement suggests that the patient's airway will
remain patent after tracheal extubation.
2) measuring the intrathoracic pressure required to produce a
“leak” around the endotracheal tube with the cuff deflated.
3)In volume controlled ventillation expiratory tidal volume can
be calculated before and after cuff deflation.
 Patients who require reintubation generally have a smaller
leak.

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Management
 Patients with airway obstruction should receive
supplemental oxygen
 A combined jaw-thrust and head-tilt maneuver pulls the
tongue forward and opens the airway.
 Insertion of an oral or nasal airway also often alleviates the
problem.
 Any secretions or blood in the hypopharynx should be
suctioned
 Postoperative wound hematomas following head and neck,
thyroid, and carotid procedures can quickly compromise
the airway; opening the wound immediately relieves
tracheal compression.

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 Mask-ventilation of a patient with severe upper airway
obstruction resulting from edema or hematoma may be
difficult
 Ready access to difficult airway equipments.
 Surgical backup for performance of an emergency
tracheostomy.
 Dexamethasone (0.5 mg/kg)or aerosolized racemic
epinephrine (0.5 mL of a 2.25% solution with 3 mL of
normal saline) may be useful in some cases.

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 Obstructive Sleep Apnea
 Obstructive sleep apnea syndrome is often an overlooked
cause of airway obstruction in the PACU.
 Patients with OSA are particularly prone to airway
obstruction and should not be extubated until they are
fully awake and following commands.
 Continuous regional anesthesia techniques should be used
to provide postoperative analgesia.
 In patient with OSA, plans should be made preoperatively
to provide CPAP in the immediate postoperative period.

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 Hypoxemia in PACU
 Mild hypoxemia is common in patients recovering
from anesthesia unless supplemental oxygen is given
during emergence.
 The routine use of a pulse oximeter in the PACU
facilitates early detection.
 ABG measurements should be performed to confirm
the diagnosis and guide therapy.
 Clinically- restlessness, tachycardia, or cardiac
irritability (ventricular or atrial). Obtundation,
bradycardia, hypotension, and cardiac arrest are late
signs.
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Factors contributing to postop hypoxemia

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Alveolar Hypoventilation
 PaCO2 more than 45 mm of hg. – Hypoventilation

 Significant hypoventilation clinically -PaCO2 is greater

than 60 mm Hg or arterial blood pH is less than 7.25.

 Prolonged somnolence, airway obstruction, slow

respiratory rate, tachypnea with shallow breathing, or
labored breathing.

 Mild to moderate respiratory acidosis causes

tachycardia and hypertension or cardiac irritability
and even circulatory depression.
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 Even a patient with a normal lungs may become hypoxemic
if continue to hypoventilate while breathing room air.

Management
 Arterial hypoxemia secondary to hypercapnia can be
reversed by the administration of supplemental oxygen.

 External stimulation of the patient to wakefulness.

 Pharmacologic reversal of opioid or benzodiazepine effect

or controlled mechanical ventilation of the patient's lungs.

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Pulmonary edema
 Pulmonary edema in the immediate postoperative
period is often cardiogenic in nature secondary to
intravascular volume overload or CHF.

 Less common cause includes postobstructive

pulmonary edema , sepsis and TRALI.

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Postobstructive Pulmonary Edema
 Transudative edema produced by the exaggerated
negative intrathoracic pressure generated by an
inspiratory effort against a closed glottis.

 Muscular healthy patients are at increased risk of

postobstructive pulmonay edema.

 Laryngospasm is the most common cause.

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 Arterial hypoxemia is usually manifested within 90
minutes of the upper airway obstruction and is
accompanied by bilateral fluffy infiltrates on the chest
radiograph.

Treatment is supportive and includes

 supplemental oxygen
 diuresis
 positive-pressure ventilation

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Supplemental Oxygen
 The choice of oxygen delivery system in the PACU is
determined by the degree of hypoxemia, the surgical
procedure, and patient compliance.

 Nasal cannula with bubble humidifier with flow of 6

L/min provides FIO2 of approximately 0.44.

 The other methods are through Hudson mask, Face tent

oxygen or blow-by setups.

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Transfusion-Related Lung Injury
 Pulmonary edema in the PACU may include transfusion-
related lung injury in any patient who received blood
products intraoperatively.

 Typically manifested within 1 to 2 hours(maximum 6 hrs)

after the transfusion of plasma-containing blood products.

 The resulting noncardiogenic pulmonary edema is often

associated with fever and systemic hypotension.

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Diagnostic criteria for TRALI

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Management
 Treatment is supportive and includes supplemental
oxygen and drug-induced diuresis.
 Mechanical ventilation may be needed to support
hypoxemia and respiratory failure.
 Vasopressors may be required to treat refractory
hypotension.

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Noninvansive ventilation
 An effective alternative to endotracheal intubation in the ICU
setting.
 Noninvasive modes of ventilation in the PACU must be guided
by careful consideration
Contraindications
 hemodynamic instability
 life-threatening arrhythmias
 altered mental status,
 high risk of aspiration,
 inability to use nasal or facial mask (head and neck procedures)
 refractory hypoxemia
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Continuous Positive Airway Pressure
 8% to 10% of patients who undergo abdominal surgery
subsequently require intubation and mechanical
ventilation in the PACU.
 The application of CPAP in this setting can decrease
hypoxemia due to atelectasis by recruiting alveoli.
 Increases functional reserve capacity may also improve
pulmonary compliance.
 Application of CPAP in the PACU significantly reduced
the incidence of reintubation, pneumonia, respiratory
faliure, and sepsis.

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(6)Hemodynamic Instability
Hypertension

 Common in PACU and usually within 30 min of arrival.

 Patients with a history of essential hypertension are at greatest

risk.

 Postoperative systemic hypertension and tachycardia are

associated with an increased risk of unplanned critical care
admission and a higher mortality .

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Factors leading to postoperative
hypertension

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Management
 Mild hypertension generally does not require
treatment
 Marked hypertension can precipitate postoperative
bleeding, myocardial ischemia, heart failure, or
intracranial hemorrhage.
 Any reversible cause should be identified and treated.
 Blood pressure greater than 20–30% of the patient's
normal baseline or those associated with adverse
effects should be treated.

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 Mild to moderate Hypertension should treated
with β-adrenergic blocker such as labetalol, esmolol,
or propranolol; or calcium channel blocker or
nitroglycerine patch.

 Severe Hypertension should be treated with

intravenous infusion of nitroprusside, nitroglycerin,
nicardipine, or fenoldopam .

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 Hypovolemia
 Most common cause of the shock during perioperative
period.
1. Ongoing third-space translocation of fluid
2. inadequate intraoperative fluid replacement
3. loss of sympathetic nervous system tone.
4. Ongoing bleeding should be ruled out.

 Patient should be managed with iv fluids, blood

products and vasopressor if required.

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Causes of Systemic Hypotension

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Distributive (Decreased Afterload)
 Physiologic derangements, like iatrogenic
sympathectomy, critical illness, allergic reactions, and
sepsis.
 Neuromuscular blocking drugs are the most common
cause of anaphylactic reactions in the operative setting
followed by latex allergy
 Epinephrine is the drug of choice to treat hypotension
secondary to an allergic reaction.
 If sepsis is suspected it is managed with fluid resuscitation
, vasopressors and broad spectrum antibiotics.

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 Cardiogenic (Intrinsic Pump Failure)
 Cardiogenic causes of include
1. myocardial ischemia and infarction
2. cardiomyopathy
3. cardiac tamponade
4. cardiac dysrhythmias.

 In low-risk patients (<45 years of age, no known cardiac

disease, only one risk factor), postoperative ST-segment
changes on the ECG do not usually indicate myocardial
ischemia.
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Cardiac Dysrhythmias
Reversible causes of cardiac dysrhythmias in the
perioperative period include
 hypoxemia
 hypoventilation and associated hypercapnia,
 endogenous or exogenous catecholamines,
 electrolyte abnormalities
 acidemia
 fluid overload
 anemia
 substance withdrawal
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 Sinus Tachycardia
Common causes Less common causes
 pain  Bleeding
 agitation  cardiogenic or septic
 hypercapnia shock
 hypovolemia  pulmonary embolism
 shivering  thyroid storm
 malignant
hyperthermia

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 Atrial dysrrythmias
 The incidence of new postoperative atrial
dysrhythmias may be as high as 10% after major
noncardiothoracic surgery

 New-onset atrial dysrhythmias associated with a

longer hospital stay and increased mortality.

 Postoperative atrial fibrillation risk is increased by

preexisting cardiac risk factors, positive fluid balance,
electrolyte abnormalities, and oxygen desaturation.
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 Ventricular Dysrhythmias
 Premature ventricular contractions (PVCs) and
ventricular bigeminy occur commonly in the PACU.

 True ventricular tachycardia is rare and is indicative of

underlying cardiac pathology.

 Torsades de pointes, may precipitate in patients of QT

prolongation on the electrocardiogram by intrinsic or
drug related (amiodarone, procainamide, or
droperidol
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 Bradydysrhythmias
 Most commonly iatrogenic
 Drug-related causes include β-blocker therapy,
anticholinesterase , opioid , and dexmedetomidine.
 Procedure- and patient-related causes include bowel
distention, increased intracranial or intraocular
pressure, and spinal anesthesia.

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(7)Renal Dysfunction
 Oliguria is defined as urine output<o.5ml/Kg/hr.
 The differential diagnosis of postoperative renal
dysfunction includes prerenal, intrarenal, and
postrenal causes
 Frequently, the cause is multifactorial
 Urinary catheter obstruction or dislodgment is easily
remedied and often overlooked
 Details of the surgical procedure (urologic or
gynecologic) should be sought to rule out anatomic
obstruction or disruption of the ureters, bladder, or
urethra.
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Postoperative oliguria

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Summarize
 PACU is more than a postanaesthesia observation
room.
 It support the care of patients of all ages and at every
stage of illness.
 Important complications in post anaesthesia are Pain,
PONV , delerium , airway obstruction.
 The anesthesiologist is responsible for managing the
patient in the PACU.
 Since its inception PACU has proved to be an
exceptionally adaptable unit equipped to meet the
demand of evolving health system.

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THANK YOU
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