BY RAJEEV KUMAR

Location & size:  Should be close to the operating room with immediate assess to the blood bank , x-ray, blood gas & laboratory service.  1.5 PACU beds per operating room or 2 bed for
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every 4 procedure.

Continous oxygen supply Laryngoscope Ambu bag ETT Suction Airways ± oral - nasopharyngeal

PACU should contain all essential monitors like pulse oximetry ECG Capnograpry Temperature monitoring NIBP

Should have,  Large doors  Adequate lightning  Sufficient electrical and plumbing facilities  Efficient environmental control  Central nursing station and physician station  Storage and utility room

Standard for PACU were updated in 1994 by ASA house of delegates STANDARD 1 ` All patients who have received GA/RA/monitored anaesthesia should receive appropriate post anaesthesia management STANDARD 2 ` Patient should be transported to PACU with member of anaesthesia team and continously evaluated and treated during transport STANDARD 3 ` Status of the patient should be documented in PACU ` Information about preoperative and operative condition shall be transmitted to nurse 

STANDARD 4 ` Particular attention should be given to monitoring, oxygenation, ventilation, circulation and temperature in PACU ` Use of appropriate PACU scoring system is encouraged ` Assure the availability of managing complication and providing CPR STANDARD 5 ` A physician is responsible for the discharge of the patient from PACU ` In absence of physician, PACU nurse will dischrge the patient according to discharge criteria

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Emergance from GA should idealy be a smooth and gradual awakenig in controlled environment It begins in operative room or during transport in recovery room and frequently associated withAirway obstruction Shivering Agitation & delirium Nausea, vomiting Pain Hypothernmia & autonomic lability

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Speed of emergance depend on following coditionIn case of inhalational anesthetic speed of recovery is directally proportional to alveolar ventillation & inversaly proportional to blood solubility of agent As duration of anestheia increases emergance become depend on tissue uptake of agent Hypoventilation delays emergence from inhallationl anesthesia

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Primaraly depend upon redistribution. As the dose increases , due to cummulative effect ,emergance increasingly become depends on elimination or metabolic half life. Advanced age, renal ,hepatic impairement can also delay emergance due to decrease elimintion rate.

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Defined as inabilty to gain conciosness even after 3060 min. its causes areresidual anesthetic ,sedative effect hypothermia metabolic disturbances intra-operatie stroke hypoxia, hypercarbia hyper-calcemia,hypo-glycemia,hyper-glycemia, hypo-natremia

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Depends on suspected cause asnaloxone(for opiods) ± in 0.04mg iv increamental doses flumazenil(for BZD)-0.2mg iv incremental doses physostigmine(for iv & inhallational anesthetic)1-2mg iv Hypothermia should be treated with rewarming, and warm fluids. Metabolic &electrolyte disturbance should be corrected.

This period is usually complicated by lack ofadequate monitor. emergency drugs resuscitative equipment Pateint should not leave operative room unless they havestable & patent airway adequate ventillation and oxygenation hemodynamic stablity Oxygen delivery ` Unstable pateint should be left intubated & transported with a portable monitor(ECG, Spo2, BP)& supply of emergancy drugs & oxygen source
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All pateint shoud be taken to PACU on bed that can be placed in either in head down or head up position Head down for (trendelenbug position)-usefull for hypovolumic position Head up position is useful for pulmonary dysfunction Pateint high risk forvomiting airway bleeding & airway obstrction should be kept in lateral position

RESPIRATORY COMPLICATIONairway obstruction and hypovenilation 2 CIRCULATORY COMPLICATIONhypotention , hypertension, arrythmia 3 FAILURE TO REGAIN CONCIOUSNESS 4 NAUSEA AND VOMTING 5 HYPOTHERMIA & SHIVERING 6 POSTOPERATIVE PAIN
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AIRWAY OBSTRUCTION: CAUSES:  Tongue falling (pharyngeal obstruction)
a combination of jaw trust and backward tilt of the head is often useful. Nasal or oral airway 

Laryngeal obstruction
May be due to laryngeal spasm, direct airway injury,or vocal card paralysis Laryngeal spasm is sometimes relieved by anterior displacement of mandible, if this maneuvre fail 10mg dexamethasone iv is given All patient with airway obstruction should receive oxygen Positive pressure ventilation If spasm is not relieved by above menuvres, then succinycholine 10 to 20 mg with positive pressure ventilation should be given Suction of pharyngeal collections to prevent furthur laryngospasm 

Glottic edema
Common in paediatric patients Treated with iv dexamethasone 0.5 mg/kg Arosolized adrenaline 0.5 ml of 2.25% solution with 3 ml of normal saline 

Poatoperative wound hematoma in neck compremissing airway should be drained immediately

HYPOVENTILATION:  Defined as reduced alveolar ventilation resulting in increase in PaCO2 > 45mmHg  it causes prolonged somnalence, slow respiratory rate, tachypnea, laboured breathing  Causes are, opioid overdose, inadequate reversal, splinting due to incisional pain, obesity, diaphragmatic dysfunction or tight abdominal dressing, abdominal distension and hypothermia  Treatment
Marked hypoventilation always require controlled ventilation until causes are identified and corrected Opioid induced respiratory depression is treated with 0.04 mg naloxone iv in incremental dose, alternatively doxaprame 60 to 100mg followed by 1 to 2mg/min iv is useful For releaving pain ollowing upper abdominal and thoracic surgery, epidural analgesia, intercostal block, and judicious use of opioid is useful

HYPOXEMIA:  Defined as Pao2 <50 to 60 mmHg  Main causes are low inspired concentration of oxygen, hypoventilation, area of low V/Q ratio, increased intrapulmonary Right to Left shunt  Treatment
Oxygen therapy is the cornerstone of therapy with or without positive pressure ventilation Routinely 30 to 60% oxygen is given, in patients having underlying cardiac or respiratory disease may need higher concentration If hypoxemia is not corrected with this concentration 100% is given with positive pressure ventilation Associated medical condition should be optimized

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CAUSES:
inadeqate intraoperative fluid replacement Continued third spacing & wound drainage Postoperative bleeding Relative hypovolumia- epidural- spinal anesthesia, rewarming, Sepsis & allergic reaction Ventricular dysfunction-metabolic acidosis,hypoxia,sepsis,coonary artery ,valvular heart deases, arrythmia

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Significant hypotension defined as 2o-30% reducton from baseline BP, require treatment. Increase in BP following fluid bolus of 250-500ml crystalloids or colloid 100-250ml ,generally conferms hypovolumia. In severe hypotension vasopressor or inotrope may be necessory to increase BP, until volume deficit is corrected cardiac dysfunction should be sought in elderly pateint & patient with heart disease. Tension pneumothorax is suggested by hypotension unilateral decreasd heart sound,hyperresonance & tracheal deviation ±is indication of immediate pleural aspiration

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Postoperative hypertension is common in PACU, its CAUSES are ±
Incisional pain, endotracheal intubation, bladder distension. Secondary to hypoxemia,hypercapnia,metabolic acidosis. Fluid overload or intracranial hypertension

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BP greater than 20-30% of patient¶s normal baseline or those associated with adverse effect ( such as MI, heart failure or bleeding) should be treated. Mild to moderate hypertension can be treated with labetalol, esmolol propanplol, nicardipine or NTG patch. Marked hypertension in patient with limited cardiac reserve, require, intra-arteial BP monitoring and should be treated with iv infusion of SNP, NTG, nicardipine, fenoldepam.

CAUSES:
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Hypoximia, hypercabia, acidosis. Hypokalemia, hypomagnesemia,increased sympathetic tone. Bradycardia- resudual effect of neostigmine - beta blocker - opioids Tachycardia- pain, fever, hpovolumia, anemia. -anticholinergic agent(atropine) -vagolytic drugs(pancuronium, meperidine)

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This occurs in up to 80% of patients following anaesthesia and surgery.
1. Predisposing factors:

Risk factors for PONV are,
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Young age Female gender Anxiety DM H/O motion sickness Early pregnancy

2. Increased gastric volume:
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Obesity Excessive anxiety
3. Anaesthetic technique:

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Nitrous oxide Ketamine Neostigmine
4. Surgery:

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Laproscopy Ear surgery Squint surgery Ovum retrieval Orchiopexy

5. Postoperative cause:
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Pain Movement Hypotension

Drugs used for management of PONV, ` 5-HT3 (hydroxytryptamine) antagonists Ondansetron. Adults 4± 8mg intravenously or orally, 8 hourly. Has both central and peripheral actions; in the gut it blocks 5-HT3 receptors in the mucosal vagal afferents ` Dopamine antagonists Metoclopramide, Adults 10mg intravenously, intramuscularly or orally, 6 hourly. Although a specific anti-emetic, minimal effect against PONV. Has an effect at the chemoreceptor trigger zone and increases gastric motility. ` An alternative is domperidone 10mg orally. ` Phenothiazine derivatives Prochlorperazine Adults 12.5mg intramuscularly 6 hourly or 15±30mg orally, daily in divided doses. May cause hypotension due to alpha-blockade. Some have antihistamine activity and may cause dystonic muscle movements.

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Anticholinergic drugs Atropine and hyoscine; are also can be used because of its vagolytic activity, Severe side-effects, particularly dry mouth and blurred vision. Steroids Dexamethasone 8mg IV may be useful in resistant cases. Antihistamines Cyclizine. Adults 50mg intramuscularly, up to 6 hourly. Also has anticholinergic actions; may cause a tachycardia when given IV. 

Droperidol is a butyrophenone, which is a antagonist at dopamine receotor. Its use may cause dyskinesia, restlessness and dysphoric reaction upto 24 hour after surgery  Lorazepam is also tried and it is as effective as droperidol

After injury, acute pain limits activity until healing has taken place. Ineffective treatment of postoperative pain not only delays this process, but also has other important consequences: ` Physical immobility:
reduced cough, sputum retention and pneumonia; muscle wasting, skin breakdown and cardiovascular deconditioning; thromboembolic disease²deep venous thrombosis and pulmonary embolus; delayed bone and soft tissue healing.

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Psychological reaction:
reluctance to undergo further, necessary surgical procedures.

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Economic costs:
prolonged hospital stay, increased medical complications; increased time away from normal occupations.

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Development of chronic pain syndromes.

Factors affecting the experience of pain ` Anxiety heightens the experience of pain. ` Patients who have a pre-existing chronic pain problem are vulnerable to suffering with additional acute pain. ` Upper abdominal and thoracic surgery cause the most severe pain of the longest duration, control of which is important because of the detrimental effects on ventilation. Management of postoperative pain ` This can be divided into a number of steps:
assessment of pain ± given in next page analgesic drugs used; techniques of administration; difficult pain problems.

Pain score 0

Staff view None

Patient¶s view

Action

Insignificant or no pain

Consider reducing dose or changing to weaker analgesic, e.g. morphine to NSAID plus paracetamol Continue current therapy, review regularly

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Mild

In pain, but expected and tolerable; no reason to seek (additional) treatment Unpleasant situation; treatment desirable but not necessarily at the expense of severe treatment side-effects Intolerable situation²will consider even unpleasant treatments to reduce pain

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Moderat e

Continue current therapy, consider additional regular simple analgesia, e.g. paracetamol and/or NSAIDS

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Severe

Increase dose of opioid, or start opioid; consider alternative technique, e.g. epidural

Analgesic drugs used postoperatively
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Simple analgesia,
Paracetamol is a weak anti-inflammatory agent Modulates prostaglandin production in the central nervous system Can be administered orally or rectally Best taken on a regular rather than 'as required' basis. Overdose results in hepatic necrosis Often combined with weak opiates (e.g. dihydrocodeine = Co-dydramol)

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Non-steroidal anti-inflammatory agents
Inhibit the enzyme cyclo-oxygenase Reduces prostaglandin, prostacyclin and thromboxane production Also have weak central analgesic effect Often used for their 'opiate sparing' effects Side effects include:
x x x x Gastric irritation and peptic ulceration Precipitation of bronchospasm in asthmatics Impairment of renal function Platelet dysfunction and bleeding

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Opiates
Most commonly used drugs are diamorphine, morphine and pethidine Diamorphine is a prodrug rapidly hydrolysed to morphine and 6-monoacetyl-morphine More lipid soluble than morphine with greater central effects Pethidine has only about 10% the analgesic potency of morphine All act on mu receptors in brain and spinal cord Mu 1 receptors are responsible for analgesia Mu 2 receptors are responsible for respiratory depression Side effects of opiates include:
x x x x x x x Sedation Nausea and vomiting Vasodilatation and myocardial depression Pruritus Delayed gastric emptying Constipation Urinary retention

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Routes of opiate administration
Oral - available for codeine, dihydrocodeine and oramorph Subcutaneous - useful for chronic pain relief Intramuscular - produces peaks and troughs in pain relief Intravenous - reliable but can produce sedation and respiratory depression Patient-controlled analgesia (PCA) - patient determines own analgesic requirement
x 'Lock-out' period prevents accidental overdose x Safe as sedation occurs before respiratory depression

Epidural or spinal
x Lipid soluble opiates (e.g. fentanyl) are normally used x Produces good analgesia with reduced risk of side effects

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Regional analgesic techniques
Peripheral nerve blocks Used mainly for pain relief after upper or lower limb surgery. A single injection of local anaesthetic, usually bupivacaine, results in 6±12h of pain relief. Epidural analgesia, Infusions of a local anaesthetic into the epidural space, either alone or in combination with opioids, act on the transiting nerve roots and the dorsal horn of the spinal cord, respectively, to provide dramatic relief of postoperative pain. For upper abdominal surgery an epidural in the mid-thoracic region (T6/7) is used, while a hip operation would need a lumbar epidural (L1/2). Intrathecal (spinal) analgesia, Spinal anaesthesia is of insufficient duration to provide postoperative pain relief. However, if a small dose of opioid, for example morphine 0.1±0.25 mg, is injected along with the local anaesthetic, this may provide up to 24 h of analgesia. Complications are the same as those due to opioids given epidurally, and managed in the same way.

Difficult pain problems ` Patients in whom there is evidence of regular opioid use preoperatively, for example drug addicts, cancer and chronic pain patients and those patients with a previous bad pain experience, will pose a particular problem postoperatively. 

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By pushing a button patient are able to self administer precise dose the drug The physician programs the infusion pump to deliver a specific dose Lock out period- minimum interval between the dose, usually 1to4 hrs PCA can be used in both epidural and intravenously Opioid is usually used for analgesia in PCA

Opioid Morphine

Bolus dose 1-3 mg

Lockout time (min) 10-20

Infusion rate 0-1mg/hr

Meperidine Fentanyl Hydromorphone

10-15 mg 15-25 microgram 0.1-0.3mg

5-15 10-20 10-20

0-20mg/hr 0-50microgram/hr 0-0.5mg/hr

Opioid

Bolus dose

Lockout time (min)

Infusion rate

Morphine

0.2-0.3mg

30

0.3-0.9mg/hr

Fentanyl

20-30 microgram

15

25-50 microgram/hr

Hydromorphone

0.15 microgram

30

0.1-0.2 microgram/hr

Cry

Not crying Crying

Score 0 Score 1 Score 0 Score 1 Score 0 Score 1 Score 0

Posture

Relaxed Tense

Tense

Relaxed or happy Distressed

Response

Responds when spoken to No response

Score 1

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Because of ischemic heart disease, diminished pulmonary capacity, altered drug clearance, or increased drug sensitivity, the elderly patient is probably more vulnerable to the physiologic consequences of inadequate analgesia, as well as to the side effects of analgesic use Intensive pain management strategies may be indicated in high-risk elderly patients or in low-risk elderly patients undergoing high-risk surgery

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Patient must be evaluated by anasthesiologist prior to discharge from PACU Criteria can vary according to whether patient is going to be discharged to regular ward, ICU, or home Patient receiving regional anaesthesia should also so sign resolution of both sensory and motor blockade Recovery of proprioception, sympathetic tone, bladder function and motor strength are additional criteria following regional anaesthesia

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Consciousness 2 = Fully awake 1 = Responds to name 0 = No response Activity on command 2 = Moves all extremities 1 = Moves two extremities 0 = No movement Respiration 2 = Free deep breathing 1 = Dyspneic, hyperventilating, obstructed breathing 0 = Apneic

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Circulation 2 = Blood pressure within 20% of pre-op level 1 = Blood pressure within 50%±20% of pre-op level 0 = Blood pressure 50%, or less, of pre-op level Oxygen saturation 2 = SpO2 >92% on room air 1 = Supplemental O2 required to maintain SpO2 >92% 0 = SpO 2 <92% with O2 supplementation

Total Score is 10, minimum 9 is required for discharge.

1. Vital Signs ` 2=within 20% of preoperative value ` 1=20% to 40% of preoperative value ` 0=40% of preoperative value 2. Activity, mental status ` 2=Orientated and steady gait ` 1=Orientated or steady gait ` 0=Neither 3. Pain ` 2=minimal ` 1=moderate ` 0=severe

4. Surgical bleeding ` 2=minimal ` 1=moderate ` 0=severe 5. nausea and vomiting ` 2=minimal ` 1=moderate ` 0=severe

Maximum score = 10, patients scoring 9 are fit for discharge

Fast tracking By passing the postanaesthetic care after outpatient surgery is termed as fast tracking. It is based on the following criteria, ` Level of consciousness ` Physical activity ` Respiratory stability ` Hemodynamic stability ` O2 saturation

Postop pain ` Nausea and vomiting Each of this criteria is having score 0, 1, 2. The total score over 12 with no individual score <1 is required for fast tracking.
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