RECOVERY ROOM

CARE
BY
RAJEEV KUMAR
DESIGN
 Location & size:
 Should be close to the operating room with

immediate assess to the blood bank , x-ray,

blood gas & laboratory service.
 1.5 PACU beds per operating room or 2 bed

for every 4 procedure.

EQUIPMENTS
◦ Continous oxygen supply
◦ Laryngoscope
◦ Ambu bag
◦ ETT
◦ Suction
◦ Airways – oral
- nasopharyngeal
MONITORS
PACU should contain all essential monitors
like
◦ pulse oximetry
◦ ECG
◦ Capnograpry
◦ Temperature monitoring
◦ NIBP
FACILITIES

Should have,
 Large doors
 Adequate lightning
 Sufficient electrical and plumbing facilities
 Efficient environmental control
 Central nursing station and physician station
 Storage and utility room
PACU STANDARDS
 Standard for PACU were updated in 1994 by ASA house of
delegates
STANDARD 1
 All patients who have received GA/RA/monitored

anaesthesia should receive appropriate post anaesthesia

management
STANDARD 2
 Patient should be transported to PACU with member of

anaesthesia team and continously evaluated and treated

during transport
STANDARD 3
 Status of the patient should be documented in PACU
 Information about preoperative and operative condition

shall be transmitted to nurse

PACU STANDARDS
STANDARD 4
 Particular attention should be given to monitoring,

oxygenation, ventilation, circulation and temperature

in PACU
 Use of appropriate PACU scoring system is

encouraged
 Assure the availability of managing complication and

providing CPR
STANDARD 5
 A physician is responsible for the discharge of the

patient from PACU

 In absence of physician, PACU nurse will dischrge the

patient according to discharge criteria

EMERGANCE FROM G.A.
 Emergance from GA should idealy be a smooth
and gradual awakenig in controlled environment
 It begins in operative room or during transport in
recovery room and frequently associated with-
Airway obstruction
Shivering
Agitation & delirium
Nausea, vomiting
Pain
Hypothernmia & autonomic lability
Emergance from inhalational agent
 Speed of emergance depend on following
codition-
 In case of inhalational anesthetic speed of

recovery is directally proportional to alveolar

ventillation & inversaly proportional to blood
solubility of agent
 As duration of anestheia increases emergance

become depend on tissue uptake of agent

 Hypoventilation delays emergence from

inhallationl anesthesia
Emergence from IV agent
 Primaraly depend upon redistribution.
 As the dose increases , due to cummulative

effect ,emergance increasingly become

depends on elimination or metabolic half life.
 Advanced age, renal ,hepatic impairement

can also delay emergance due to decrease

elimintion rate.
DELAYED EMERGENCE
 Defined as inabilty to gain conciosness even after
30-60 min.
 its causes are-

residual anesthetic ,sedative effect

hypothermia
metabolic disturbances
intra-operatie stroke
hypoxia, hypercarbia
hyper-calcemia,hypo-glycemia,hyper-
glycemia,
hypo-natremia
Tretment of delayed emergance
 Depends on suspected cause as-
naloxone(for opiods) – in 0.04mg iv
increamental doses
flumazenil(for BZD)-0.2mg iv incremental doses
physostigmine(for iv & inhallational
anesthetic)- 1-2mg iv
 Hypothermia should be treated with rewarming,
and warm fluids.
 Metabolic &electrolyte disturbance should be
corrected.
Transport from operative room
 This period is usually complicated by lack of-
adequate monitor.
emergency drugs
resuscitative equipment
Pateint should not leave operative room unless they have-
stable & patent airway
adequate ventillation and oxygenation
hemodynamic stablity
Oxygen delivery
 Unstable pateint should be left intubated & transported

with a portable monitor(ECG, Spo2, BP)& supply of

emergancy drugs & oxygen source
 All pateint shoud be taken to PACU on bed
that can be placed in either in head down or
head up position
 Head down for (trendelenbug position)-

usefull for hypovolumic position

 Head up position is useful for pulmonary

dysfunction
 Pateint high risk forvomiting airway bleeding

& airway obstrction should be kept in lateral

position
COMPLICATONS IN RECOVERY
ROOM
1.RESPIRATORY COMPLICATION-
airway obstruction and hypovenilation
2 CIRCULATORY COMPLICATION-
hypotention , hypertension, arrythmia
3 FAILURE TO REGAIN CONCIOUSNESS
4 NAUSEA AND VOMTING
5 HYPOTHERMIA & SHIVERING
6 POSTOPERATIVE PAIN
MANEGMENT OF COMPLICATIONS
AIRWAY OBSTRUCTION:
CAUSES:
 Tongue falling (pharyngeal obstruction)
◦ a combination of jaw trust and backward tilt of the head is often
useful.
◦ Nasal or oral airway
 Laryngeal obstruction
◦ May be due to laryngeal spasm, direct airway injury,or vocal card
paralysis
◦ Laryngeal spasm is sometimes relieved by anterior displacement
of mandible, if this maneuvre fail 10mg dexamethasone iv is given
◦ All patient with airway obstruction should receive oxygen
◦ Positive pressure ventilation
◦ If spasm is not relieved by above menuvres, then succinycholine
10 to 20 mg with positive pressure ventilation should be given
◦ Suction of pharyngeal collections to prevent furthur laryngospasm
 Glottic edema
◦ Common in paediatric patients
◦ Treated with iv dexamethasone 0.5 mg/kg
◦ Arosolized adrenaline 0.5 ml of 2.25% solution with 3
ml of normal saline

 Poatoperative
wound hematoma in neck
compremissing airway should be drained
immediately
HYPOVENTILATION:
 Defined as reduced alveolar ventilation resulting in

increase in PaCO2 > 45mmHg

 it causes prolonged somnalence, slow respiratory rate,

tachypnea, laboured breathing

 Causes are, opioid overdose, inadequate reversal,

splinting due to incisional pain, obesity, diaphragmatic

dysfunction or tight abdominal dressing, abdominal
distension and hypothermia
 Treatment
◦ Marked hypoventilation always require controlled ventilation
until causes are identified and corrected
◦ Opioid induced respiratory depression is treated with 0.04 mg
naloxone iv in incremental dose, alternatively doxaprame 60 to
100mg followed by 1 to 2mg/min iv is useful
◦ For releaving pain ollowing upper abdominal and thoracic
surgery, epidural analgesia, intercostal block, and judicious use
of opioid is useful
HYPOXEMIA:
 Defined as Pao2 <50 to 60 mmHg
 Main causes are low inspired concentration of

oxygen, hypoventilation, area of low V/Q ratio,

increased intrapulmonary Right to Left shunt
 Treatment
◦ Oxygen therapy is the cornerstone of therapy with or
without positive pressure ventilation
◦ Routinely 30 to 60% oxygen is given, in patients
having underlying cardiac or respiratory disease may
need higher concentration
◦ If hypoxemia is not corrected with this concentration
100% is given with positive pressure ventilation
◦ Associated medical condition should be optimized
 HYPOTENSION
 CAUSES:
◦ inadeqate intraoperative fluid replacement
◦ Continued third spacing & wound drainage
◦ Postoperative bleeding
◦ Relative hypovolumia- epidural- spinal anesthesia,
rewarming,
◦ Sepsis & allergic reaction
◦ Ventricular dysfunction-metabolic
acidosis,hypoxia,sepsis,coonary artery ,valvular
heart deases, arrythmia
 Treatment of hypotension
 Significant hypotension defined as 2o-30%
reducton from baseline BP, require treatment.
 Increase in BP following fluid bolus of 250-500ml
crystalloids or colloid 100-250ml ,generally
conferms hypovolumia.
 In severe hypotension vasopressor or inotrope may
be necessory to increase BP, until volume deficit is
corrected
 cardiac dysfunction should be sought in elderly
pateint & patient with heart disease.
 Tension pneumothorax is suggested by
hypotension unilateral decreasd heart
sound,hyperresonance & tracheal deviation –is
indication of immediate pleural aspiration
 HYPERTENSION
 Postoperative hypertension is common in
PACU, its CAUSES are –
◦ Incisional pain, endotracheal intubation, bladder
distension.
◦ Secondary to hypoxemia,hypercapnia,metabolic
acidosis.
◦ Fluid overload or intracranial hypertension
Treatment of postoperative
hypertension
 BP greater than 20-30% of patient’s normal
baseline or those associated with adverse
effect ( such as MI, heart failure or bleeding)
should be treated.
 Mild to moderate hypertension can be treated
with labetalol, esmolol propanplol, nicardipine
or NTG patch.
 Marked hypertension in patient with limited
cardiac reserve, require, intra-arteial BP
monitoring and should be treated with iv
infusion of SNP, NTG, nicardipine, fenoldepam.
 ARRHYTHMIAS
CAUSES:
 Hypoximia, hypercabia, acidosis.
 Hypokalemia, hypomagnesemia,increased

sympathetic tone.
 Bradycardia- resudual effect of neostigmine

- beta blocker
- opioids
 Tachycardia- pain, fever, hpovolumia, anemia.

-anticholinergic agent(atropine)
-vagolytic drugs(pancuronium,
meperidine)
 Postoperative nausea and vomiting
(PONV)
 This occurs in up to 80% of patients following
anaesthesia and surgery.

Risk factors for PONV are,

1. Predisposing factors:
 Young age
 Female gender
 Anxiety
 DM
 H/O motion sickness
 Early pregnancy
 2. Increased gastric volume:
 Obesity
 Excessive anxiety

3. Anaesthetic technique:
 Nitrous oxide
 Ketamine
 Neostigmine

4. Surgery:
 Laproscopy
 Ear surgery
 Squint surgery
 Ovum retrieval
 Orchiopexy
 5. Postoperative cause:

 Pain
 Movement
 Hypotension

Drugs used for management of PONV,

 5-HT3 (hydroxytryptamine) antagonists Ondansetron. Adults 4–

8mg intravenously or orally, 8 hourly. Has both central and

peripheral actions; in the gut it blocks 5-HT3 receptors in the
mucosal vagal afferents
 Dopamine antagonists Metoclopramide, Adults 10mg

intravenously, intramuscularly or orally, 6 hourly. Although a

specific anti-emetic, minimal effect against PONV. Has an effect at
the chemoreceptor trigger zone and increases gastric motility.
 An alternative is domperidone 10mg orally.
 Phenothiazine derivatives Prochlorperazine Adults 12.5mg

intramuscularly 6 hourly or 15–30mg orally, daily in divided doses.

May cause hypotension due to alpha-blockade. Some have
antihistamine activity and may cause dystonic muscle movements.
 Anticholinergic drugs Atropine and hyoscine; are
also can be used because of its vagolytic activity,
Severe side-effects, particularly dry mouth and
blurred vision.
 Steroids Dexamethasone 8mg IV may be useful in

resistant cases.
 Antihistamines Cyclizine. Adults 50mg

intramuscularly, up to 6 hourly. Also has

anticholinergic actions; may cause a tachycardia
when given IV.
 Droperidol is a butyrophenone, which is a antagonist at
dopamine receotor. Its use may cause dyskinesia,
restlessness and dysphoric reaction upto 24 hour after
surgery
 Lorazepam is also tried and it is as effective as
droperidol
POSTOPERATIVE PAIN
After injury, acute pain limits activity until
healing has taken place.
Ineffective treatment of postoperative pain not
only delays this process, but also has other
important consequences:
 Physical immobility:

◦ reduced cough, sputum retention and pneumonia;

◦ muscle wasting, skin breakdown and cardiovascular
deconditioning;
◦ thromboembolic disease—deep venous thrombosis
and pulmonary embolus;
◦ delayed bone and soft tissue healing.
 Psychological reaction:
◦ reluctance to undergo further, necessary surgical
procedures.
 Economic costs:
◦ prolonged hospital stay, increased medical
complications;
◦ increased time away from normal occupations.
 Development of chronic pain syndromes.
Factors affecting the experience of pain
 Anxiety heightens the experience of pain.
 Patients who have a pre-existing chronic pain

problem are vulnerable to suffering with

additional acute pain.
 Upper abdominal and thoracic surgery cause the

most severe pain of the longest duration, control

of which is important because of the detrimental
effects on ventilation.
Management of postoperative pain
 This can be divided into a number of steps:

◦ assessment of pain – given in next page

◦ analgesic drugs used;
◦ techniques of administration;
◦ difficult pain problems.
Pain Staff Patient’s view Action
score view

0 None Insignificant or no pain Consider reducing dose or

changing to weaker analgesic,
e.g. morphine to NSAID plus
paracetamol

1 Mild In pain, but expected Continue current therapy,

and tolerable; no reason review regularly
to seek (additional)
treatment

2 Moderat Unpleasant situation; Continue current therapy,

e treatment desirable but consider additional regular
not necessarily at the simple analgesia, e.g.
expense of severe paracetamol and/or NSAIDS
treatment side-effects
Analgesic drugs used postoperatively

 Simple analgesia,
◦ Paracetamol is a weak anti-inflammatory agent
◦ Modulates prostaglandin production in the central
nervous system
◦ Can be administered orally or rectally
◦ Best taken on a regular rather than 'as required' basis.
◦ Overdose results in hepatic necrosis
◦ Often combined with weak opiates (e.g.
dihydrocodeine = Co-dydramol)
 Non-steroidal anti-inflammatory agents
◦ Inhibit the enzyme cyclo-oxygenase
◦ Reduces prostaglandin, prostacyclin and thromboxane
production
◦ Also have weak central analgesic effect
◦ Often used for their 'opiate sparing' effects
◦ Side effects include:
 Gastric irritation and peptic ulceration
 Precipitation of bronchospasm in asthmatics
 Impairment of renal function
 Platelet dysfunction and bleeding
 Opiates
◦ Most commonly used drugs are diamorphine, morphine and
pethidine
◦ Diamorphine is a prodrug rapidly hydrolysed to morphine and
6-monoacetyl-morphine
◦ More lipid soluble than morphine with greater central effects
◦ Pethidine has only about 10% the analgesic potency of morphine
◦ All act on mu receptors in brain and spinal cord
◦ Mu 1 receptors are responsible for analgesia
◦ Mu 2 receptors are responsible for respiratory depression
◦ Side effects of opiates include:
 Sedation
 Nausea and vomiting
 Vasodilatation and myocardial depression
 Pruritus
 Delayed gastric emptying
 Constipation
 Urinary retention
 Routes of opiate administration
◦ Oral - available for codeine, dihydrocodeine and
oramorph
◦ Subcutaneous - useful for chronic pain relief
◦ Intramuscular - produces peaks and troughs in pain
relief
◦ Intravenous - reliable but can produce sedation and
respiratory depression
◦ Patient-controlled analgesia (PCA) - patient
determines own analgesic requirement
 'Lock-out' period prevents accidental overdose
 Safe as sedation occurs before respiratory depression
◦ Epidural or spinal
 Lipid soluble opiates (e.g. fentanyl) are normally used
 Produces good analgesia with reduced risk of side
effects
 Regional analgesic techniques
◦ Peripheral nerve blocks Used mainly for pain relief after upper
or lower limb surgery. A single injection of local anaesthetic,
usually bupivacaine, results in 6–12h of pain relief.
◦ Epidural analgesia, Infusions of a local anaesthetic into the
epidural space, either alone or in combination with opioids,
act on the transiting nerve roots and the dorsal horn of the
spinal cord, respectively, to provide dramatic relief of
postoperative pain. For upper abdominal surgery an epidural
in the mid-thoracic region (T6/7) is used, while a hip
operation would need a lumbar epidural (L1/2).
◦ Intrathecal (spinal) analgesia, Spinal anaesthesia is of
insufficient duration to provide postoperative pain relief.
However, if a small dose of opioid, for example morphine 0.1–
0.25 mg, is injected along with the local anaesthetic, this may
provide up to 24 h of analgesia. Complications are the same
as those due to opioids given epidurally, and managed in the
same way.
Difficult pain problems
 Patients in whom there is evidence of regular

opioid use preoperatively, for example drug

addicts, cancer and chronic pain patients and
those patients with a previous bad pain
experience, will pose a particular problem
postoperatively.
Patient controlled analgesia

 By pushing a button patient are able to self

administer precise dose the drug
 The physician programs the infusion pump to

deliver a specific dose

 Lock out period- minimum interval between the

dose, usually 1to4 hrs

 PCA can be used in both epidural and

intravenously
 Opioid is usually used for analgesia in PCA
 Intravenous PCA
Opioid Bolus dose Lockout time Infusion rate
(min)
Morphine 1-3 mg 10-20 0-1mg/hr

Meperidine 10-15 mg 5-15 0-20mg/hr

Fentanyl 15-25 10-20 0-50microgram/hr

microgram
Hydromorphone 0.1-0.3mg 10-20 0-0.5mg/hr
Epidural PCA
Opioid Bolus dose Lockout time Infusion rate
(min)

Morphine 0.2-0.3mg 30 0.3-0.9mg/hr

Fentanyl 20-30 15 25-50

microgram microgram/hr

Hydromorphone 0.15 microgram 30 0.1-0.2

microgram/hr
 Pain assessment for children under four years

Cry Not crying Score 0

Crying Score 1
Posture Relaxed Score 0
Tense Score 1
Tense Relaxed Score 0
or happy
Distressed Score 1
Response Responds when Score 0
spoken to
No response Score 1
Pain Management in elderly

 Because of ischemic heart disease, diminished

pulmonary capacity, altered drug clearance, or
increased drug sensitivity, the elderly patient is
probably more vulnerable to the physiologic
consequences of inadequate analgesia, as well
as to the side effects of analgesic use
 Intensive pain management strategies may be

indicated in high-risk elderly patients or in low-

risk elderly patients undergoing high-risk
surgery
DISCHARGE
 Patient must be evaluated by anasthesiologist
prior to discharge from PACU
 Criteria can vary according to whether patient is

going to be discharged to regular ward, ICU, or

home
 Patient receiving regional anaesthesia should

also so sign resolution of both sensory and

motor blockade
 Recovery of proprioception, sympathetic tone,

bladder function and motor strength are

additional criteria following regional
anaesthesia
Modified Aldrete Score
(Postanesthesia Recovery Score)
 Consciousness
2 = Fully awake
1 = Responds to name
0 = No response
 Activity on command
2 = Moves all extremities
1 = Moves two extremities
0 = No movement
 Respiration
2 = Free deep breathing
1 = Dyspneic, hyperventilating, obstructed
breathing
0 = Apneic
 Circulation
2 = Blood pressure within 20% of pre-op level
1 = Blood pressure within 50%–20% of pre-op
level
0 = Blood pressure 50%, or less, of pre-op
level
 Oxygen saturation
2 = SpO2 >92% on room air
1 = Supplemental O2 required to maintain
SpO2 >92%
0 = SpO 2 <92% with O2 supplementation

Total Score is 10, minimum 9 is required for

discharge.
Post Anaesthesia Discharge Scoring
System (PADS)
1. Vital Signs
 2=within 20% of preoperative value
 1=20% to 40% of preoperative value
 0=40% of preoperative value

2. Activity, mental status

 2=Orientated and steady gait
 1=Orientated or steady gait
 0=Neither

3. Pain
 2=minimal
 1=moderate
 0=severe
4. Surgical bleeding
 2=minimal
 1=moderate
 0=severe

5. nausea and vomiting

 2=minimal
 1=moderate
 0=severe

Maximum score = 10, patients scoring 9 are

fit for discharge
Fast tracking
By passing the postanaesthetic care after
outpatient surgery is termed as fast
tracking.
It is based on the following criteria,
 Level of consciousness
 Physical activity
 Respiratory stability
 Hemodynamic stability
 O2 saturation
 Postop pain
 Nausea and vomiting

Each of this criteria is having score 0, 1, 2.

The total score over 12 with no individual score
<1 is required for fast tracking.