POST ANESTHESIA CARE UNIT

(PACU)

Department of Anesthesiology &

Reanimation
School of Medicine, Malahayati University/
Abdul Moeloek General Hospital
Bandar Lampung

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Design of PACU
• Near the operating room and other
Intensive Care facilities
• Open ward (to facilitate observation of all
patients simultaneously)
• well lighted (day light)

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Equipment
• Pulse oxymetri
• ECG
• BP monitor
• Warming/cooling blanket
• Emergency trolley
• outlets : oxygen, electrical, suction
• minor set
• infusion/syringe pump
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Before world war II
Post operative death after anesthesia and
surgery is high
This period is characterized by relatively
high incidence of potentially life threatening.
Respiratory and circulatory complications.
After world war II
Success of RR  factor in evaluation of
modern ICU/PACU
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Staffing

• Nurses - trained in care of emerging

Patients ( ACLS)
- I Nurse for 2 Beds ( Patients )
• Medical direction of an Anesthesiologist
Coordinated to Surgeon and any
consultants

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Emergence from Anesthesia
• Because post operative is a time of
great physiologic stress.
Ex…….. - Airway obstruction
- Shivering
- Vomite ...etc.
• Delayed Emergence
• When the patients fail to regain
consciousness 60-90 minute following
general anesthesia ( G.A.)
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The causes

• Residual Anesthetic
• Sedative
• Prolong effect of opiate
• Hypothermia
• Metabolic Disturbances
• Perioperative stroke (rare)

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 Post op/post anesthesia Management

•Monitoring: - vital sign - BP

–Pulse/HR
–RR
- Oxygen supplementation (SpO2)
- Temp
- Sensory and motor level
(Regional Anesthesia)

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Pain control
- parenteral
- Regional anesthesia
- Nerve Block
Agitation/Restlessness
- cause ? (hipoxemia, acidosis etc)
Nausea and vomiting
cause ?  hypotension by
- regional anesthesia
- opioid
- vagal tone
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Shivering
cause ?
- Unwarmed I.v. fluids
- Exposure of large wound
- AC
- Hyperthermia
- Metabolic acidosis ect
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Complications in PACU
1. Airway obstruction
- Unconscious patients 
tongue
falling
back against the posterior
pharynx
- Larynx spasm
- Glottic edema etc
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2. Hypoventilation
- Defined as PaCO2 > 45 mmHg
pH < 7,25
- Causes
- Residual depressant effect of
anesthesia agents
(overdose)
- In adequate reversal
- Severe pain
- Tight abdominal dressing
- CO2 production is high
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3. Hypoxaemia
Defined as PaO2 < 70 mmHg
Causes
- Hypoventilation
- Oxygen consumption
- FRC
- Lung - edema

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4. Hypotension
- Defined as A 20-30% reduction
of BP
- Causes
- Hypovolemia
- Ventricular
dysfunction
- Impaired cardiac filling

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5. Hypertension
Defined as BP > 20-30% of base
line
Causes
Sympathetic activation
- pain
- hypercapnia

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6. Arrhythmia
- Hypercarbia
- Electrolyte disturbances
- Residual effects of
cholinesterase inhibitor

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Discharge criteria
- must be evaluated
- after 60 minutes in the PACU
_____________________________________
Parameters Value
____________________________________
color - pink 2
- pale 1
- cyanotic 0
_____________________________________
Respiration - Breathe deeply & cough 2
- Shallow but adequate 1
- apnea 2

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_____________________________________
Circulation
BP within 20% of normal 2
20-50% 1
50% from normal 0
________________________________________________
_
Consciousness
- awake/alert 2
- arousable 1
- no response 0
________________________________________________
_
Activity
- move all extr 2
- move 2 extr 1
- no movement 0
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INTENSIVE CARE UNIT (ICU)
- Multi disciplinary
- As intensive care with potentially
life threatening illness
- Supporting therapies
- neurologic
- cardiovascular/hemodynamic
- Pulmonary/respiratory
- Electrolyte/metabolism
- Nutritional
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NEUROLOGIC SUPPORT
- CBF is constant  auto regulation
at range of BP (MAP 50-
150mmHg)
- Injury losses of ability
autoregulation
- CBF related to CPP
(CPP = MAP-ICP)

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ACUTE CNS INJURY
- Ischemia (focal or generalize)
- Structural distortion of brain
- Scoring – GCS
- CNS support is focused on
- optimizing systemic & cerebral B.F
- normalizing ICP

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-Immediate concerns
- airway/ventilation/oxygenation
- hemodynamic issues
-Hypotension (loss of automatic control)
- Hypertension (hyper adrenergic state)
- Cardiac dysfunction
- Seizures control (metabolic/infections)
- Neurologic exam
- Is there a surgical lession ?
- GCS
- Laboratory
- CT Scan
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SUPPORTIVE CARE
- General treatment
- Oxygenation
- Correct anemia
- Hemodynamic stability
- Establish normovolemia
- Control hyperthermia
- Control seizures
- control pain
- Avoid agitation/shivering
- correct metabolic abnormalities
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-Control ICP
- CSF (volume reduction)
- Hyperventilation
- Osmotic agent
- Barbiturate
- Head position
- To be prevent vasospasm
- Steroid (?)

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CARDIOVASCULAR/HEMODYNAMIC
SUPPORT
-Major determinants of cardiac output (C.O)
- Heart rate & Contractility
- Blood Vessels
- Volume Intra vascular
- Pre Load
- After Load
- Oxygen Delivery
- C O = HR x 3 V

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*SV Is Determined By
- Preload
- After load
- Contractility
* Clinical Measurements
- Preload - Echo Cardiography
- PCWP
After load = SVR
= MAF - CV x 80
C. O
Contractility = ECHO  = EF
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• Oxygen Delivery (D O2)
D O2 = Ca O2 x C O x 10
= (HB x 1.34 x Sa O2)
+(PaO2 x 0,031) x C. O x 10

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SHOCK
* Characterized BV
- Organ Blood Flow that Is Inadequate
to meet Tissue Demands
* Four Categories Of Shock
1. Cardiogenic Shock
- Co 
- PCWP 
- SVR 

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2. Hypovolemic Shock
- CO
- PCWP
- SVR 
3. Distributive Shock
- CO N/ 
- PCWP N / 
- SVR 
4. Obstructive Shock
- CO 
- PCWP 
-SVR
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 MANAGEMENT OF SHOCK

- Increasing C.O
- Therapy Arrhythmias
- To Manage - Pre Load
- After Load
- Fluid
- Improve Contractility
- Optimize Oxygen Delivery
- Hemoglobin
- P a O2 (FiO2 & Lung Function)
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- Vaso Pressor & Inotropic Agent
- Dopamine. etc
- Antibiotic
- Decrease Oxygen Demand

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Respiratory Support
One of Most Common Disorder Leading to 1cm
Admission is ARF (Acute Respiratory Failure)
ARF. - When the Pulmonary system is no
longer able to meet the metabolic
demands of the body

Two types of respiratory failure (RF)

Type I Hypoxemic RF (PaO2  50TORR)
Type II Hypercapmic RF (PaCO2  50 TORR)
- with hypoxemic
- without hypoxemic
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Causes of RF
Type I (Usually the result of mismatch of
alveolar ventilation and pulmonary
perfusion)
Example - Acute lung injury
- Acute pulmonary edema
Type II (Characterized by alveolar
hypoventilation)
Example - Airflow obstruction
- CNS
- Neuromuscular disturbances

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CLINICAL MANIFESTATIONS OF ARF
IS ARDS
- Onset 12-72 hours after triggers
- Respiratory distress (gasping, cyanotic etc)
- Lung edema (non cardiogenic)
- PaO2 < 50mmHg
- CPWP > 18mmHg
- PaO2/FiO2 < 200mmHg
Management
- Oxygen supplement
- nasal canula
- face mask
- IPPV – non invasive
- Pharmacologic
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ELECTROLYTE DISTURBANCES
Es the most common disturbances are in K+
Na+ Ca+
A. Potassium (N.3,5-5,5 mEq/L)
1. Hypokalemia (K+ < 3,5 mEq/L)
Causes - Renal & extra renal losses
- Transcellular shift
- Decreased intake
Clinical - Arrhythmias
- ECG. Abnormalities
- Muscle Weakness
- Ileus Etc.
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TREATMENT
- Correcting The Underlying Cause
- Stop Offending Drubs
- Correct The Potassium level
- K + > 3 Meg /L . KCL 20-40 Meg/4-6
MRS . Orally/NGT
- K + <2,5 Meg /L – KCL 20-30 Meg
/HRS Intravenously

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2. HYPERKALEMIK ( K+>5,5 mEq/L
- Most often from renal dysfunction
- Other Causes
- Acidemia
- Hypoaldosteronism
- Cell Death (Hemolysis,
Burnsetc)
- Excessive Intake

Clinical - Arrhythmias
- Muscle Weakness
- Paralysis. etc.
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TREATMENT
- Underlying cause
- Stop Offending Drugs
- Limitation of Potassium
- Correcting
- ECG Abnormalities are present
- CaCl2 10 % 5-10 ml (i.v.5-10 mnt)
- Sodium Bicarbonate
1 Meg /Kg BW /I.V 5-10 mnt.
- 10 IU RI. In 10 Ml Dext.50 %/IV/10’
- Dialysis
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3. SODIUM (N 135 - 145 mEq/L)
1. Hyponatremia (Na + < 135 mEq/L)
Causes
- Excess Secretion of ADH
- Non Sodium Solute Infusion
Clinical.
- CNS Disturbances
- Muscular Disturbances

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TREATMENT
- Treating the Underlying Disease
- Stop Offending Drugs
- Correcting
- Restricting free water intake
- Increasing free water clearing
- Loop diuretic
- Replace with saline 5 %
- Limit 15 mEq/L in first 24
hours
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2. HYPERNATREMI (Na + > 145 mEq/L)
Cause - Intracellular volume Depletion
with
- A Loss of free water
- Excessive sodium intake

Clinical
- CNS
- Muscle

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TREATMENT
Underlying Causes
Free water Repletion
L = 0,6 x wt [( Na1 /Na2)-1]
L = Water deficit
Na 1 = Normal Sodium Level
Na 2 = Measured
Wt = KS

- Correcting . 12-20 Meg /C/24HRS

- Dialysis
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METABOLIC DISTURBANCES
Hyperglycemic Syndromes
- Life Threatening Hyperglycemic syndrome
1. Diabetic Ketoacidosis (DKA)
2. Hyperglycemic Hyperosmolar Nonketotic
syndrome (H1 + NK)
Clinical
- Osmotic Diuresis  Dehydration
- Weakness
- CNS Manifestation
- Odor to the Breath
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TREATMENT
- The Goals are
- Restore the Fluid & Electrolyte Balance
- Provide Insulin
- Identify Precipitating Factor

- NS. 20 ml/ kg for First Hour

Then. 250-500 ml/Hr AS Needed
After that
- NS 0,5 % Maintenance
- Insulin (R1) 5-10 IU
Followed By 5-10 IU /HR. (0,1 IU /kg/HR)
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 IF Glucose Level  250 Mg %
- Glucose Containing Fluid (1/V)
(Maintain Glucose level >150
By Insulin S.C.
IF Glucose Level < 150 mg %
- Glucose 10 %
IF PH < 7.0
- Consider Bicarbonate

- Correcting the Serum level (if Present)

- Potasium
- Phosphorus
- Magnesium
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