POSTANESTHESIA

CARE

DHANY BUDIPRATAMA
TEXT BOOK READING
Recovery rooms  exist for + 40 years
One or more nurses could pay close attention
to several patients at one time
Major factor in the evolution of modern
surgical ICU
Patient  PACU, following any type of
anesthesia
Recovery phases for outpatient surgery :
 Phase 1 : Immediate intensive care level
recovery  PACU
 Phase 2 : lower level care  go home
PACU design

Should be located near OR

Proximity to radiographic, laboratory, and
other Intensive Care facilities on the same
floor
At least one enclosed patient space
Ratio  3 PACU beds : 2 Operating rooms
Each patient space  well lighted and large
enough, have multiple electrical outlet for
oxygen, air and suction
Equipment

Each space  Pulse oximetry (SpO2), ECG,

automated blood pressure monitors.
All monitors  should be used for every patient in
phase 1 care.
Capnography  useful for intubated patients.
A forced-air warming device, heating lamps and
warming/cooling blanket should be available.
PACU should have its own supplies of basic and
emergency equipment (oxygen cannulae, masks,
oral and nasal airways, and self-inflating bags for
ventilation).
Staffing

Should be staffed only by nurses :

 Specifically trained in the care of patients emerging
from anesthesia.
 Have expertise in airway management and ACLS.
Should be under the medical direction of an
anesthesiologist.
Management of the patient in the PACU  should
reflect a coordinated between the anesthesiologist,
surgeon and any consultants.
Inadequate staffing  major factor to mishaps in
the PACU
Emergence from General
Anesthesia
Should ideally be a smooth and gradual awakening
in a controlled environtment
Often begins in the OR or during transport to the RR
Characterized by :
Airway Obstruction
Shivering
Agitation
Delirium
Pain
Nausea and vomiting, etc
Delayed Emergence

The most frequent : residual anesthetic,

sedative and analgesic drug effect.
Less common : hypothermia, metabolic
disturbances, and perioperative stroke.
Administration of naloxone (0,04 mg
increments) & flumazenil (0,2 mg increments)
 reverses & exclude the effects of opioid
A nerve stimulator  exclude neuromuscular
blockade in patients on a mechanical
ventilator
Emergence following an inhalational-based
anesthetic :
- Directly  alveolar ventilation
- Inversely  agent’s blood solubility
Duration of anesthesia  Emergence
Hypoventilation delays emergence from inhalational
anesthesia
Recovery from I.V. anesthetic agent’s  dependent
on redistribution rather than elimination half-life
The speed of emergence  influenced by preop
medication
Transport from The Operating Room

Usually complicated by : the lack of adequate

monitors, access to drugs or resuscitative equipment
Patients  OR, unless :
Have a stable and patent airway
Have adequate ventilation & oxygenation
Hemodynamically stable
Unstable patients  left intubated, transported w/
portable monitor (ECG, SpO2, and BP) and a supply
of emergency drugs
Bed Position :
Head-down  hypovolemic patients
Head-up  patients with underlying
pulmonary disfunction
Patients at high risk for vomiting or upper airway
bleeding (ex. Following tonsillectomy)  lateral
position
Lateral position  prevent airway obstruction &
facilitates drainage of secretions
Routine Recovery
General Anesthesia

Vital signs & oxygenation  checked immediately

on arrival
BP, Pulse rate & RR  checked at least every 5’
for 15’ or until stable, & every 15’ thereafter
Pulse oxymetri  until they regain consciousness
Temperature  at least once
Anesthesiologist  brief report to the PACU nurse
Patients should generally be nursed in the head-up
position whenever possible to optimize oxygenation
Routine Recovery
Regional Anesthesia

Give supplemental oxygen

Sensory & motor levels  periodically
recorded
Blood Pressure  closely monitored following
spinal & epidural anesthesia
Bladder catheterization  patients who have
had spinal or epidural anesthesia > 4 hours
Routine Recovery
Pain Control
Moderate to severe postoperative pain  parenteral
or intraspinal opioids, regional anesthesia or nerve
block
Adequate analgesia must be balanced against
excessive sedation
Most commonly used :
Meperidine, 10-20mg (0,25-0,5mg/kg in
children)
Morphine, 2-4mg (0,025-0,05mg/kg in children)
Patient is fully awake  patient-controlled analgesia
Epidural catheter :
Fentanyl, 50-100μg
Sufentanil, 20-30μg
Morphine, 3-5mg
Mild to moderate pain can be treated :
Butorphanol, 1-2mg
Nalbuphine, 5-10mg
Ketorolac tromethamine, 30mg
Routine Recovery
Agitation
Pain is often manifested as postoperative
restless- ness
Systemic disturbances, bladder distention,
or surgical complication should be
considered
Other factors :
Preoperative anxiety and fear
Adverse drug effects
Physostigmine, 1-2mg i.v (0,05mg/kg in
children)  treating delirium due to atropine
and scopolamin
Routine Recovery
Nausea and Vomiting
Nausea  may be seen with hypotension from
spinal or epidural anesthesia
Incidence  opioid and possibly nitrous
oxide anesthesia, intraperitoneal surgery and
strabismus surgery
Highest incidence  young women
Propofol anesthesia  << nausea and
vomiting
Intraoperatif  droperidol 0,625-1,25mg (0,05-
0,075mg/kg in children)
Metoclopramide, 0,15mg/kg i.v  less drowsiness
Ondansetron 4mg (0,1mg/kg in children),
granisetron (0,01-0,04mg/kg) and dolasetron
12,5mg (0,035mg/kg in children)  also effective
Ondansetron  more effective than other agents in
children
Dexamethasone, 8-10mg (0,10mg/kg in children) +
another antiemetic  effective for refractory nausea
and vomiting
Low dose propofol (20mg bolus, or a 10mg bolus
followed 10μg/kg/min)  effective
Routine Recovery
Shivering & Hypothermia

Shivering  result of introperative hypothermia

or the effects of anesthetic agents
The most important cause of hypothermia 
redistribution of heat from the body core to the
peripheral compartments
Nearly all anesthetics  << normal
vasoconstrictive response to hypothermia
Shivering  the body’s effort to increase heat
production & raise body temperature
Shivering  duration of surgery & use of high
concentration of volatile agent
Spinal & epidural anesthesia  shivering
threshold & vasoconstrictive response to
hypothermia
Meperidine 10-50mg  Shivering
Hypothermia associated with :
Incidence of myocardial ischemia
Arrhytmias
Transfusion requirements
Duration of muscle relaxant effects
Discharge Criteria

Criteria can vary

Before discharge  patient observed for at least
30’ after the last dose of parenteral narcotic
Minimum discharge criteria :
Easy arousability
Full orientation
The ability to maintain & protect the airway
Stable vital signs for at least 30-60 minutes
The ability to call for help if necessary
No obvious surgical complications
 Postanesthetic Aldrete recovery score

Original Criteria Modified Criteria Point

Value
Color Oxygenation
Pink SpO2 > 92% on room air 2
Pale or dusky SpO2 > 92% on oxygen 1
Cyanotic SpO2 > 92% on oxygen 0

Respiration
Can breathe deeply & cough Breathes deeply & coughs freely 2
Shallow but adequate exchange Dyspneic,shallow or limited breathing 1
Apnea or obstruction Apnea 0

Circulation
Blood pressure within 20% of normal Blood pressure within +20mmHg of normal 2
Blood pressure within 20-50% of normal Blood pressure within +20-50mmHg of normal 1
Blood pressure deviating >50% from normal Blood pressure > 50mmHg of normal 0

Consciousness
Awake,alert, and oriented Fully awake 2
Arousable but readily drifts back to sleep Arousable on calling 1
No response Not responsive 0

Activity
Moves all extremities Same 2
Moves two extremities Same 1
No Movement Same 0
Patients receiving RA  should show sign of
resolution of both sensory & motor blockade
Failure of spinal or epidural block to resolve
after 6 hours  possibility of spinal cord or
epidural hematoma
Respiratory Complications
Airway Obstruction
Most commonly due to the tongue falling back
against the posterior pharynx
Other causes : laryngospasm, glottic edema,
secretions, vomitus, blood in the airway or
external pressure on the trachea
Patients with airway obstruction 
supplemental oxygen, maneuvers
Laryngospasm  high-pitched crowing noises
but may be silent, with complete glottic closure
Laryngospasm treatment :
Jaw-thrust maneuver
Temporary positive airway pressure with
100% oxygen via a tight-fitting face mask
A small dose of succinylcholine (10-20mg)
In infants & young children  Glottic edema
In that case  corticosteroids
(dexamethasone, 0,5mg/kg) or aerosolized
racemic epinephrine (0,5mL of a 2,25%
solution with 3mL of NS)
Respiratory Complication
Hypoventilation
Defined as PaCO2 > 45mmHg
PaCO2 > 60mmHg or arterial blood pH < 7,25
 Significant hypoventilation
Signs :
Prolonged somnolence
Airway obstruction
Slow respiratory rate
Tachypnea with shallow breathing
Or Labored breathing
Hypoventilation in the PACU  the residual
depressant effect of anesthetic agents on
respiratory drive.
Residual muscle paralysis in the PACU :
Inadequate reversal
Overdose
Hypothermia
Pharmacologic interaction
Altered pharmacokinetics
Metabolic factors
Treatment  should generally be directed at
the underlying cause
Marked hypoventilation always requires
controlled ventilation
Obtundation, circulatory depression, severe
acidosis (pH< 7,15)  endotracheal intubation
Naloxone :
The abrupt increase in alveolar ventilation
(titration with 0,04mg in adults)
Precipitate a hypertensive crisis, pulmonary
edema, and myocardial ischemia or
infarction
Respiratory Complication
Hypoxemia
Mild to moderate hypoxemia (PaO2 50-60mmHg)
 in young healthy patients may be well tolerated
initially  progressive acidosis & circulatory
depression
Hypoxemia may be suspected :
Restlessness
Tachycardia
Cardiac irritability
Obtundation, bradycardia, hypotension, cardiac
arrest
ABG measurements  confirm the diagnosis and
guide therapy
Hypoxemia usually caused by : hypoventilation,
increased right-to-left intrapulmonary shunting, or
both
Routine administration of 30-60% oxygen is
usually enough to prevent hypoxemia
Patients with severe or persistent hypoxemia 
100% oxygen via NRFM or an endotracheal tube
A chest tube  inserted for any simptomatic
pneumothorax or one that is > 15-20%
Bronchospasm  aerosolized bronchodilators or
aminophylline i.v
Circulatory Complications
Hypotension
Usually due to :
Decreased venous return to the heart
Left ventricular dysfuntion
Excessive arterial vasodilation
Hypovolemia : absolute and relative
Associated with sepsis & allergic reactions 
hypovolemia & vasodilation
Following a tension pneumothorax  impaired
cardiac filling
Ventricular dysfunction  patients underlying
coronary artery & valvular heart disease
Mild hypotension during recovery from anesthesia
 typically does not require treatment
Significant hypotension : a 20-30% reduction of
blood pressure below the patient’s baseline level &
indicates a serious requiring treatment
Increase in BP following a fluid bolus (250-500mL
crystalloid or 100-250mL colloid)  hypovolemia
Failure to respond to treatment  invasive
hemodynamic monitoring, manipulations of cardiac
preload, contractility, and afterload
Tension pneumothorax  pleural aspiration
Cardiac tamponade  pericardiocentesis
Circulatory Complications
Hypertension
Typically occurs within the first 30’ in the PACU
Reflect :
Stimulation from incisional pain
Endotracheal intubation
Bladder distention
Fluid overload or intracranial hypertension
In general : BP elevations > 20-30% of the
patients normal baseline or those associated with
adverse effect  should be treated
Mild to moderate elevations  intravenous β-
adre- nergic blocker or calcium channel
blocker
Sublingual nifedipine & hydralazine 
effective but causes tachycardia & associated
with myocardial ischaemia and infarction
The end point for treatment  consistent with
the patients own normal blood pressure
Circulatory Complications
Arrhytmias
Predispose :
Residual effects from anesthetic agents
Increased sympathetic nervous system activity
Metabolic abnormalities
Preexisting cardiac or pulmonary disease
Bradycardia  the residual effects of a
cholinesterase inhibitor, a potent synthetic opioid
or β-adrenergic blockers
Tachycardia  the effect of an anticholinergic
agent, a vagolytic drug, a β-agonist, reflex
tachycardia, pain, fever, hypovolemia & anemia
Perioperative causes of tachycardia
Anxiety Drug-induced
Pain Antimuscarinic agents
Fever β-Adrenergic agonists
Respiratory Vasodilators
Hypoxemia Allergy
Hypercapnia Drug withdrawl
Circulatory Metabolic disorders
Hypotension Hypoglycemia
Anemia Thyrotoxicosis
Hypovolemia Pheochromocytoma
Congestive heart failure Adrenal (addisonian) crisis
Cardiac tamponade Carcinoid syndrome
Tension pneumothorax Acute porphyria
Thromboembolism