DELAYED

EMERGENCE IN
POST ANESTHESIA
CARE UNIT (PACU)
Achmed Rizal

Pembimbing
Dr. dr. RTH Supraptomo, Sp.An, KAO
 ABSTRACT
A 65-years-old woman, has been carried out at the PACU with
delayed appearance and causes of postoperative hypercarbia
inflammation. Handling done at the PACU includes alveolar
improvement by protecting the effectiveness of the airway and
managing the airway always clean with periodic suction and assisting
ventilation. After 90 minutes in the PACU the patient recovers and
discarged to High Care unit following 1 hour monitoring.
Introduction
Delayed emergence is a failure to get the
expected awareness within 60 minutes after
the end of the operating procedure.

Delayed emergence is more common in

patients aged ≥ 60 years

The time of emergence anesthesia is very

variable and depends on patient factors, the
depth of surgery, and the type of anesthesia
(alveolar ventilation, solubility of the blood
agent, premedication)
 Literature review
CORTICAL AWARENESS MECHANISM
1. Reticular activation system
2. Cortical Neural Pathways
3. Cortical neurotransmitters
4. Acetylchholin
5. Aminobutyric acid
 Literature review

Causes of delayed emergence

Evaluation and Management of Delayed Emergence
Case
A 65-year-old woman with an pancreatic head mass was
done Biliodigest laparotomy procedure

Her past medical history included the whole body is

colored yellowish. The patient also complained of pain in
the upper abdomen, weakness and decreased appetite

Allergies (-) asthma (-)

DM (-) HT (-)
Surgery (-)
Fasting for 6 hours pre op
The patient comes with a surgical poly surgery plan. Nausea
(-) vomiting (-) shortness (-), cough (-)
 GCS : E4V5M6
Case Airway: open the mouth 3 fingers, mallampati 2, unrestricted neck
motion
B1: RR 18 x / min, 99% SpO2, space air, supine position, SDV (+ / +), ST
(- / -)
B2: TD 108/69 mmHg, HR 77 x / min, warm acral, CRT <2 ", Heart
sounds regular, noisy (-)
B3: GCS E4V5M6, isochoric pupils, neurological deficits (-)
B4: DC is not performed, urine output> 0.5cc / kg
B5: flat abdomen, normal peristaltic sound (+), tympanic, NT (-)
B5: motoric 5/5/5/5

Laboratorium (27/04/2020)  HB 9,5 Alb 2,9 AE 3,13

EKG  Normal limit Sinus Rhythm 67 bpm Normoaxis
RO thorac  Normal limit
MRI (with contrast)
mass of the pancreatic head that constricts the distal CBD and causes
proximal CBD widening, bilateral IHBD, hepatic comunis ducts, ductus
pancreaticus, and ductus cysticus
Cholecyatitis accompanied by GB sludge
 Anesthesia assessment:
Case ASA: II
Plan: General Anesthesia Oral ETT
Post op analgesics: Morphine
Post op: Ward / HCU
Available blood: 2 prc (operator)

Evaluation of AGD results in PACU Electrolyte evaluation

pH: 7.31 BE: +2.6 Na 138
pCO2: 48 k 3.4
PO2: 102 Cl 108
Hct: 29
HCO3: 28
Total CO2: 49
O2 saturation: 99%
Arterial lactate: 0.9
Case
 Pre Operative  Durante Operation
GCS : E4V5M6 Anesthesia : 12.50-18.15
BP : 120/80mmHg
Operation : 13.05-18.00
HR : 72x/minute, regular.
RR : 18x/mnt Position : Supine
Temp : 36.5°C
Weight : 50kg o morfin syringe pump
Height : 150cm 15mcg/kg/hour
o Atracurium 10 mg
Induction drug intermittently
•Midazolam 1 mg
•Fentanyl 75mcg
•Propofol 50 mg Maintenance
•Rocuronium 25 mg – O2 : N2O = 2:2 lpm
– Sevofluran 0.8-1 mac
Case

the patient's aldrette score is airway evaluation, breathing

60 minutes in RR
still 5 and circulation

Hypoventilated SaO2 97- given naloxon 0.08 mg iv and

Ventilation Assist ,Blood Gas
100%, BP 150-160 / 90-100 repeated 2 times but did not
Analysis, Electrolyte
mmHg, HR 100-110 x /minute respond.

After 15 minutes of assisted

vetntilation, the patient
feasible to move from PACU
regained consciousness and
and post operation to HCU.
after 1 hour of observation
the aldrette score became 10
Discussion
 Conclusion
• The main management of delayed emergence
is to maintain airway, breathing and
circulation coupled with the treatment of the
underlying causes.
• One of the causes of delayed emergence is the
residual of the anesthetics agent and
hypercarbia
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thank
you!