Post Anesthesia Recovery

Core-curriculum-Aug. 2016
 History

• 1801: Earliest description of a type of recovery room came

from Newcastle Infirmary in England:

 Five bedrooms adjacent to the operating room for seriously ill

patients or who had major operations.
 Each room had 2 beds: one for the patient and one for the
nurse at night.
 History

• With the outbreak of WW II, the number of recovery rooms

increased significantly because of nursing shortage in US.
Hence, one or more nurses can provide care for several
patients at one time.
 History
• In 1947: A study over 11 years in JAMA stimulated the growth
of PACUs.
 Reviewed 306 postop. fatalities within 24 h of surgery: 47%
were preventable

• The earliest recovery areas were a combination between

PACUs and SICUs.
 Design
• PACU should be near the operating room.
• Proximity to the radiology department, lab and other
intensive care facilities is desirable.
• At least one enclosed space for isolation (infection control).
• Usually ratio 1.5 PACU beds/operating room
• Each patient space should be well lighted and large enough to
allow access to patient in spite of X-ray machine, ventilator,
poles for iv pumps.
• Multiple electric outlets and at least one for oxygen, air and
suction at each space.
 Staffing
• PACU is under the medical direction of an anesthesiologist.

• It is staffed by nurses specially trained in care of patients

emerging from anesthesia.

• Ratio nurse/patient = 1/1 for the sick; 1/2 or 1/3 regular

patients
 Summary of Recommendation for
Assessment and Monitoring
• Respiratory function
• Cardiovascular function (EKG for selected patients)
• Neuromuscular function (nerve stimulator for selected patients)
• Mental status
• Temperature
• Pain
• Nausea and vomiting
• Fluids
• Urine output and voiding (selected Patients)
• Drainage and bleeding

Practice Guidelines for Postanesthetic Care

An Updated Report by the American Society of
Anesthesiologists Task Force on Postanesthetic Care
Anesthesiology 2013; 118:291-307
 Complications in the PACU

• Emergence from general anesthesia and

surgery may be accompanied by physiologic
disturbances that affect different organs.
Hines HR, Barash PG, et al.: Complications occuring in the postanesthesia care unit: A
survey. Anesth Analg 74:503-509, 1992
 Complications in PACU
• PONV
• Respiratory
• Circulatory
• Hypothermia and shivering
• Pain
• Emergence agitation
• Postoperative delirium
• Delayed emergence
 Postoperative Nausea and Vomiting
• Incidence of postop. vomiting after GA is 30%.
• Incidence of postop. nausea is 50%.
• Unresolved PONV may result in prolonged PACU stay
and unanticipated hospital admission
Postoperative Nausea and Vomiting
Postoperative Nausea and Vomiting

Apfel et al.
Postoperative Nausea and Vomiting
Postoperative Nausea and Vomiting
Risk categories

0-1 •Low risk

2 or 3 •Medium risk
<3 •High risk
Postoperative Nausea and Vomiting
Phamacologic Antiemetics for PONV Prophylaxis
5-Hydroxytryptamine
• Ondansetron, granisetron, tropisetron
antagonists
Neurokinin-1
antagonists • Aprepitant, casopitant, rolapitant
receptor antagonists
• Dexamethasone,
Corticosteroids methylprednisolone
Butyrophenones • Droperidol, haloperidol
Antihistamines • Dimenhydrinate, meclizine

Anticholinergics • Transdermal scopolamine

Propofol • TIVA
Postoperative Nausea and Vomiting
• Apfel et al. demonstrated that effects of
antiemetics acting on different receptors are
additive; combination therapy is preferable to
using single drug alone.
 Postoperative Nausea and Vomiting
Failure/No Prophylaxis
• If N&V occurs postop. despite prophylaxis, use
antiemetic of a different class.
• If no prophylaxis was given, the recommended
treatment is low dose 5-HT3 antagonist (most
adequately studied for PONV).
• Alternatives: dexamethasone, droperidol,
propofol
• Readminister same prophylactic drug after 6
hrs., but not dexamethasone or scopolamine.
 Respiratory Complications
• Upper airway obstruction
• Hypoxemia
 Respiratory Complications
Pharyngeal
muscle
weakness

Laryngospasm Residual
NMB
UAO

Airway OSA
edema
 Respiratory Complications
UAO
Pharyngeal muscle • Residual effect of sedatives
weakness • Jaw thrust, airway
• Weak, agitated, resp. distress
Residual NMB • Support airway
• Warming, correct electrolytes

Laryngospasm • Jaw thrust, CPAP, sch small dose

• Surgical manipulation, attempts at

Airway edema intubation
• Leak test

• Sensitive to opioids, BZD

OSA • CPAP
Respiratory Complications
Management of UAO

Jaw thrust, oxygen,

Oral/nasal airway

Identify cause
 Respiratory Complications
Most common causes of arterial hypoxemia
immediately postop.

Atelectasis

Alveolar hypoventilation
 Respiratory Complications
Factors contributing to postop. arterial hypoxemia

• Decreased FRC
• CHF
• Pulmonary edema (fluid overload, NPPE)
• Aspiration
• Pulmonary embolus
• Pneumothorax
• Sepsis
• ARDS
• Obesity
• Advanced age
 Residual
sedatives/Inhal
ational
anesthetics

Abdominal
distention Residual NMB

Postop.
hypoventilation

Preexisting
pulmonary Increased CO2
disease production
 Respiratory Complications

• How does hypoventilation lead to hypoxemia ?

Respiratory Complications
Circulatory Complications

Hypertension

Hypotension

Arrhythmia
Factors leading to postoperative hypertension

Preoperative hypertension

Arterial hypoxemia/hypercapnia

Increased sympathetic nervous system

activity: agitation, pain, urinary retention,
bowel distention

Increased ICP
 Circulatory Complications
Hypotension

Decreased
Hypovolemia
afterload
Cardiogenic
• Inadequate • Sympathectomy • Cardiac
intraop. fluid • Allergic reaction ischemia/
replacement • Sepsis infarction
• Third spacing • Cardiac
• Postop. Bleeding tamponade
• Arrhythmia
 Circulatory Complications
Arrhythmia

• Perioperative arrhythmias are frequently

transient and multifactorial.
 Circulatory Complications
Arrhythmias
• Pain, agitation, hypercapnia,
hypovolemia
Sinus tachycardia • Less commonly: cardiac/septic shock,
PE, thyroid storm, MH

• Drug-related: opiates, beta-blocker

Bradycardia • Patient/procedure-related:
increased ICP, high spinal
• Increased sympathetic activity,
Premature atrial electrolyte imbalance
/ventricular beats • Rarely: cardiac pathology

Atrial •Following thoracic surgery

fibrillation
Femoral
nerve
 Hypothermia and Shivering

• Normally, the interthreshold range between

vasoconstriction and sweating is about 0.3° C.
• General anesthetics disrupt the physiological
mechanisms of thermoregulation and
decrease the threshold for vasoconstriction
and shivering.
• Neuraxial anesthesia
impairs thermoregulation
and decreases the
threshold for
vasoconstriction and
shivering ( above the
block).
Anesthetics Hypothermia

Shivering
Mechanism of normothermic shivering:

• It is suggested that postanesthesia shivering is

due to differential recovery of the brain and
spinal cord.

• The more rapid recovery of spinal cord

function is thought to result in uninhibited
spinal reflexes manifested as clonic activity
(perceived as shivering).
 Deleterious Effects of Shivering

Increased
CO2
production

Postanesthesia
shivering

Increased
Increased sympathetic
oxygen activity
consumption
(HR,BP)
 Treatment of Shivering

Mepiridine

Tramal

Clonidine

Dexmedetomidine
 Consequences of Mild Hypothermia

1 • Prolonged drug metabolism

2 • Delayed recovery from anesthesia

• Impaired coagulation and platelet
3 function
4 • Impaired immunologic function

5 • Delayed wound healing

 Pain
• Postoperative pain, especially when poorly
controlled, results in harmful acute effects
(i.e., adverse physiologic responses) and
chronic effects (i.e., delayed long-term
recovery and chronic pain).
 Emergence Agitation
• It is a transient state of marked irritation and
disassociation after discontinuation of
anesthesia which does not respond to
consoling measures.

• It occurs within the first 30 minutes of

recovery and is usually self-limited.
Factors contributing to Emergence Agitation

Patient • Age: 2-6 yrs. (preschool), higher

rate
related • Preoperative anxiety of the child
• Temperament

• Type: eye and ENT higher rate

Surgical • Pain

Inhalational • Rapid emergence after

anesthestics sevoflurane/intrinsic property of IA
 Prevention of Emergence Agitation

• Parental presence following emergence

Parents

• Midazolam ( conflicting results)

Premedication • Ketamine
• Clonidine

• Fentanyl
Adjuvants to GA • Propofol
• Clonidine, dexmedetomidine
 Postoperative Delirium

Acute decline in cognition after normal

emergence

Most commonly between postop. day 1

and 3
 Postoperative Delirium
Cause: Disturbance in neurotransmitters
activity (Ach, NE, melatonin) in response
to surgical stress

Incidence: 5-15%

Meta-analyses of RCT:No benefit of RA

over GA
 Predisposing and Precipitating Factors for
Postoperative Delirium

1 • Age above 70

2 • Cognitive impairment or depression

3 • Immobility or poor physical condition

4 • Comorbidity: severe illness

5 • Sensory impairment

6 • High risk surgery and orthopedic surgery

7 • Drugs:polypharmacy, alcoholism, psychoactive

8 • Pain
 Postoperative Delirium
Prevention
• Good nursing care with regular patient orientation to time, place and person
1

• Early mobilization and rehabilitation

2

• Having access to the spectacles and hearing aid.

3

• Avoiding, if possible, irritants as urinary catheters and unnecessary medications.

4

• Pain management
5

• Adequate fluid and nutrition

6
 Delayed Emergence

• Failure to regain consciousness 30-60 min.

after general anesthesia.
 Delayed Emergence
• Bp, exclude hypoxemia and hypercarbia, ABGs
Vital signs analysis, R/O CO2 narcosis

Residual muscle • Confirm with nerve stimulator,

paralysis sugammadex administration

Hypothermia • Especially if T is less than 33˚ C

• Opioids (bradypnea), titrate with naloxone; BZD:

Residual sedation titrate with Flumazenil
• Physostigmine:CNS sedation of anticholinergic,
scopolamine
• Hypoglycemia/hyperglycemia (DKA)
Metabolic/electrolyte
• Hyponatremia/hypernatremia-
disturbance hypocacemia/hypercalcemia

Neurologic • Increased ICP, intracerebral hemorrhage,

cerebral thromboembolism
problem • CT or MRI to confirm diagnosis
 Discharge from PACU
• Specific discharge criteria may vary, but
certain general principles are universally
applicable.
 Discharge from PACU
Minimum discharge criteria:
• Easily arousable
• Fully oriented
• Able to maintain the airway
• Airway reflexes are adequate
• Hemodynamics are close to baseline
 Discharge from PACU
1970: Aldrete devised a scoring system to
provide objective information on the physical
conditions of patients in the recovery room.
Discharge from PACU
Recommendation for Discharge from PACU
• Patients should be observed until they are no longer at
increased risk for cardiorespiratory depression.
• A mandatory minimum stay should not be required.
• Discharge criteria should be designed to minimize the risk of
CNS or cardiorespiratory depression after discharge.
• The requirement of drinking clear fluids and the routine
requirement for urination should not be part of a discharge
protocol and may only be necessary for selected patients.
• All patients should be required to have a responsible
individual accompany them home.

Practice Guidelines for Postanesthetic Care

An Updated Report by the American Society of
Anesthesiologists Task Force on Postanesthetic Care
Anesthesiology 2013; 118:291-307
THANK YOU