Post Anesthesia Recovery

Core-curriculum-Sep. 2017
 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 World War 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
 Pharmacologic 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

Anticholinergic • Transdermal scopolamine
s
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.

• Readminister same prophylactic drug after 6

hrs., but not dexamethasone or scopolamine
(long-acting drugs).
 Postoperative Nausea and Vomiting
Failure/No Prophylaxis

• If no prophylaxis was given, the recommended

treatment is low dose 5-HT3 antagonist (most
adequately studied for PONV).

• Alternatives rescue medications:

promethazine, droperidol, propofol
 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: cardiogenic or septic
shock, PE, thyroid storm, MH

• Drug-related: opiates, beta-blocker

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

Atrial • Following thoracic surgery

fibrillation
Femoral
nerve
 Hypothermia and Shivering
• Postoperative shivering occurs after general
anesthesia as well after neuraxial anesthesia.

• Postoperative shivering is usually, but not

always associated with hypothermia.
• General anesthetics disrupt the physiological
mechanisms of thermoregulation.
Mechanism of normothermic shivering:

• It is suggested that postanesthesia shivering is

due to differential recovery of the brain and
spinal cord after GA.

• The more rapid recovery of spinal cord function is

thought to result in uninhibited spinal reflexes
manifested as clonic activity (perceived as
shivering).
Anesthetics Hypothermia

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

• Age: 2-6 yrs. (preschool), higher

Patient
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

Disorientation and inability to focus 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: titrate

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

• Increased ICP, intracerebral hemorrhage,

Neurologic 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 Home 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.
• 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
• You are called to evaluate a 14-y.o. female in the PACU with
O2 desaturation. The nurse tells you that the anesthesia team
extubated her deep. You determine that she is in
laryngospasm. Which is the most appropriate first step in
management?

A. Administration of 0.5 mg/Kg Sch

B. Providing jaw thrust and CPAP
C. Administration of 2 mg/Kg propofol
D. Wait 5 min., watch and reassess
• Each of the following increases the risk of
postoperative delirium EXCEPT:

A. Pre-existing cognitive impairment

B. Advanced age
C. Alcohol abuse
D. Chronic pain
• Which of the following is the most effective in
treating postoperative shivering?

A. Fentanyl
B. Clonidine
C. Doxapram
D. Mepiridine
• Which of the following can contribute to
residual NMB?

A. Hypocalcemia
B. Hypomagnesemia
C. Alkalosis
D. Hyperthermia
• A 22-y.o. female, non-smoker with no previous
anesthetic history undergoes laparoscopic ovarian
cystectomy. Her risk of PONV is most closely
estimated by:

A. 10%
B. 20%
C. 40%
D. 5%
• All of the following are consequences of mild
to moderate hypothermia (33-35°) EXCEPT:

A. Prolongation of drug metabolism

B. Delay of wound healing
C. Increase of coagulation- factor activity
D. Inhibition of platelet function
• The most common cause of oliguria in the
immediate postoperative period:

A. Low CO
B. Hypovolemia
C. ATN
D. Renal vasoconstriction
THANK YOU