The Postanesthesia Care Unit

Jessica Lovich-Sapola MD
PACU
Recovery from anesthesia can range from
completely uncomplicated to life-threatening.
Must be managed by skilled medical and
nursing personnel.
Anesthesiologist plays a key role in
optimizing safe recovery from anesthesia.
History of the PACU
Methods of anesthesia have been available for more
than 160 years, the PACU has only been common for
the past 50 years.
1920s and 30s: several PACUs opened in the US
and abroad.
It was not until after WW II that the number of PACUs
increased significantly. This was do to the shortage of
nurses in the US.
In 1947 a study was released which showed that over
an 11 year period, nearly half of the deaths that
occurred during the first 24 hours after surgery were
preventable.
1949: having a PACU was considered a standard of
care.
PACU Staffing
One nurse to one patient for the first 15
minutes of recovery.
Then one nurse for every two patients.
The anesthesiologist responsible for the
surgical anesthetic remains responsible for
managing the patient in the PACU.


PACU Location
Should be located close to the operating suite.
Immediate access to x-ray, blood bank, blood gas and
clinical labs.
Should have 1.5 PACU beds per operating room used.
An open ward is optimal for patient observation, with
at least one isolation room.
Central nursing station.
Piped in oxygen, air, and vacuum for suction.
Requires good ventilation, because the exposure to
waste anesthetic gases may be hazardous. National
Institute of Occupational Safety (NIOSH) has
established recommended exposure limits of 25 ppm
for nitrous and 2 ppm for volatile anesthetics.
PACU Equipment
Automated BP, pulse ox, EKG, and
intravenous supports should be located at
each bed.
Area for charting, bed-side supply storage,
suction, and oxygen flow meter at each bed-
side.
Capability for arterial and CVP monitoring.
Supply of immediately available emergency
equipment. Crash cart. Defibrillator.

Admission Report
Preoperative history
Intra-operative factors:
Procedure
Type of anesthesia
EBL
UO
Assessment and report of current status
Post-operative instructions
Postoperative Pain Management
Intravenous opioids
Ketorolac and anti-inflammatory drugs
Midazolam for anxiety
Epidural
Regional analgesic blocks
PCA and PCEA
Discharge From the PACU
Aldrete Score:
Simple sum of numerical values assigned to
activity, respiration, circulation, consciousness,
and oxygen saturation.
A score of 9 out of 10 shows readiness for
discharge.

Postanesthesia Discharge Scoring System:
Modification of the Aldrete score which also
includes an assessment of pain, N/V, and surgical
bleeding, in addition to vital signs and activity.
Also, a score of 9 or 10 shows readiness for
discharge.
Aldrete Score
Activity Respiration Circulation
Consciousness
Oxygen
Saturation
2: Moves all
extremities
voluntarily/ on
command
2:Breaths deeply
and coughs
freely.
2: BP + 20 mm
of
preanesthetic
level
2:Fully awake 2: Spo2 > 92%
on room air
1: Moves 2
extremities
1: Dyspneic,
shallow or limited
breathing
1: BP + 20-50
mm of
preanesthetic
level
1: Arousable on
calling
1:Supplemental
O2 required to
maintain Spo2
>90%
0: Unable to
move
extremities
0: Apneic
0: BP + 50 mm
of preanestheic
level
0: Not responding
0: Spo2 <92% with
O2
supplementation
Postanesthesia Discharge Scoring System
Vital Signs
(BP and
Pulse)
Activity Nausea and
Vomiting
Pain Surgical
Bleeding
2: Within 20% of
preoperative
baseline
2: Steady gait,
no dizziness
2: Minimal: treat
with PO meds
2: Acceptable
control per the
patient;
controlled with
PO meds
2: Minimal: no
dressing
changes
required
1: 20-40% of
preoperative
baseline
1: Requires
assistance
1: Moderate:
treat with IM
medications
1: Not
acceptable to the
patient; not
controlled with
PO medications
1: Moderate: up
to 2 dressing
changes
0: >40% of
preoperative
baseline
0: Unable to
ambulate
0: Continues:
repeated
treatment
0: Severe: more
than 3 dressing
changes
PACU Standards
1. All patients who have received general anesthesia,
regional anesthesia, or monitored anesthesia care
should receive postanesthesia management.
2. The patient should be transported to the PACU by
a member of the anesthesia care team that is
knowledgeable about the patients condition.
3. Upon arrival in the PACU, the patient should be re-
evaluated and a verbal report should be provided to
the nurse.
4. The patient shall be evaluated continually in the
PACU.
5. A physician is responsible for discharge of the
patient.
Nausea and Vomiting
Most common complication in the PACU.

DDX:
Hypoxia
Hypotension
Pain
Anxiety
Infection
Chemotherapy
Gastrointestinal obstruction
Narcotics/ volatile anesthetics/ etomidate
Movement
Vagal response
Pregnancy
Increased ICP
Do:
IV fluids
Medications (Zofran/ Phenergan/ Promethazine)
Propofol
Respiratory Complications
Nearly two thirds of major anesthesia-related
incidents may be respiratory.
Airway obstruction
Hypoxemia
Low inspired concentration of oxygen
Hypoventilation
Areas of low ventilation-to-perfusion ratios
Increased intrapulmonary right-to-left shunt

Respiratory Complications
Do:
Go to see the patient!
Assess the patients vital signs and respiratory
rate.
Evaluate the airway. R/o obstruction or foreign
body.
Mask ventilate with ambu if necessary.
Intubate and secure the airway.
Look for causes of hypoxia.
Send ABG, CBC, BMP. Get CXR.

Failure to Regain Consciousness
Preoperative intoxication
Residual anesthetics: IV or inhaled
Profound neuromuscular block
Profound hypothermia
Electrolyte abnormalities
Thromboembolic cerebrovascular accident
Seizure

Myocardial Ischemia
Increased risk:
History of CAD
CHF
Smoker
HTN
Tachycardia
Severe hypoxemia
Anemia
Same risk if the patient has GA or regional anesthesia.
Treatment
Oxygen, ASA, NTG, and morphine if needed
12 lead EKG
History
Consult cardiology

Fever
Causes:
Infections
Drug / blood reactions
Tissue damage
Neoplastic disorders
Metabolic disorders
Thyroid storm
Adrenal crisis
Pheochromocytoma
MH
Neuroleptic malignant syndrome
Acute porphyria
Bibliography
Miller: Millers Anesthesia, 6
th
ed. (2005)
Baresh: Clinical Anesthesia, 4
th
ed. (2001)
Morgan: Clinical Anesthesiology, 3
rd
ed.
(2002)