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POST ANESTHESIA CARE UNIT (PACU)

Department of Anesthesiology & Reanimation

School of Medicine Pattimura University/ Ambon

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)

Equipment

Pulse oxymetri ECG BP monitor Warming/cooling blanket Emergency trolley outlets : oxygen, electrical, suction minor set infusion/syringe pump

Before world war IIPost operative death after anesthesia and surgery is highThis period is characterized by relatively high incidence of potentially life threatening.Respiratory and circulatory complications.After world war IISuccess of RR factor in evaluation of modern ICU/PACU

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

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.)

The causes

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

Post op/post anesthesia Management

Monitoring: - vital sign - BP–Pulse/HR–RR

- Oxygen supplementation (SpO2)- Temp- Sensory and motor level

(Regional Anesthesia)

Pain control- parenteral- Regional anesthesia- Nerve Block

Agitation/Restlessness- cause ? (hipoxemia, acidosis

etc)Nausea and vomitingcause ? hypotension by

- regional anesthesia- opioid- vagal tone

Shiveringcause ?- Unwarmed I.v. fluids- Exposure of large wound- AC- Hyperthermia- Metabolic acidosis ect

Complications in PACU1. Airway obstruction

- Unconscious patients tongue falling

back against the posterior pharynx- Larynx spasm- Glottic edema etc

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

3. Hypoxaemia Defined as PaO2 < 70 mmHg Causes

- Hypoventilation- Oxygen consumption- FRC- Lung - edema

4. Hypotension- Defined as A 20-30%

reduction of BP- Causes

- Hypovolemia- Ventricular

dysfunction- Impaired cardiac

filling

5. Hypertension Defined as BP > 20-30% of base line Causes

Sympathetic activation- pain- hypercapnia

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

cholinesterase inhibitor

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

_____________________________________CirculationBP 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

INTENSIVE CARE UNIT (ICU)- Multi disciplinary- As intensive care with potentially life threatening illness- Supporting therapies

- neurologic-

cardiovascular/hemodynamic- Pulmonary/respiratory- Electrolyte/metabolism- Nutritional

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)

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

-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

SUPPORTIVE CARE- General treatment

- Oxygenation- Correct anemia- Hemodynamic stability- Establish normovolemia- Control hyperthermia- Control seizures- control pain- Avoid agitation/shivering- correct metabolic abnormalities

-Control ICP- CSF (volume reduction)- Hyperventilation - Osmotic agent- Barbiturate- Head position

- To be prevent vasospasm- Steroid (?)

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

* 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

• 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

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

2. Hypovolemic Shock - C O - P C W P - S V R 3. Distributive Shock - C O N / - PCWP N / - S V R 4. Obstructive Shock - C O - PCWP - S V R

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)

- Vaso Pressor & Inotropic Agent- Dopamine. etc- Antibiotic- Decrease Oxygen Demand

Respiratory SupportOne 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 bodyTwo types of respiratory failure (RF)Type I Hypoxemic RF (PaO2 50TORR)Type II Hypercapmic RF (PaCO2 50 TORR)

- with hypoxemic- without hypoxemic

Causes of RFType 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

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 < 200mmHgManagement- Oxygen supplement

- nasal canula- face mask

- IPPV – non invasive- Pharmacologic

ELECTROLYTE DISTURBANCESEs 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.

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

2. HYPERKALEMIK ( K+>5,5 mEq/L- Most often from renal dysfunction - Other Causes - Acidemia

- Hypoaldosteronism- Cell Death (Hemolysis,

Burns etc) - Excessive Intake Clinical - Arrhythmias - Muscle Weakness - Paralysis. etc.

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

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

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

2. HYPERNATREMI (Na + > 145 mEq/L) Cause –Intracellular volume Depletion with A Loss of free water

- Excessive sodium intake Clinical

- CNS- Muscle

TREATMENTUnderlying CausesFree water Repletion

L = 0,6 x wt [( Na1 /Na2)-1]L = Water deficitNa 1 = Normal Sodium LevelNa 2 = MeasuredWt = KS

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

METABOLIC DISTURBANCESHyperglycemic 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

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)

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