Postanesthesia care

After receiving anesthesia for a surgery or procedure,

a patient is sent to the postanesthesia care unit
(PACU) to recover and wake up. The PACU is a
critical care unit where the patient’s vital signs are
closely observed, pain management begins and
fluids are given.
This period is characterized by a relatively high
incidence of potentially life-threatening respiratory
and circulatory complications.
Post anesthesia care unit (PACU)
 The PACU should be located
near the operating rooms as it
ensure that the patient can be
rushed back to surgery if
needed.
 Patients in the PACU should be
under the medical direction of
an anesthesiologist who must
be immediately available to
respond to urgent or emergent
patient care problems.
Post anesthesia care unit (PACU)
Airway potency, vital signs, oxygenation and level of
consciousiness must be assessed immediately upon
PACU arrival. Blood pressure, heart rate and respiratory
rate measurements are routinely made at least every 5 min
for 15 min or until stable.
Pulse oximetry should be monitored continuously in all
patients.
Neuromuscular function should be assessed clinically
(head-lift).
Additional monitoring includes pain assessment
(numerical or descriptive scales)
Post anesthesia care unit (PACU)
All patients recovering
from general anesthesia
must receive supplemental
oxygen and pulse oximetry
monitoring during
emergence because
transient hypoxemia can
develop even in healthy
patients.
Pain control
 Moderate to severe postoperative
pain is most commonly treated
with oral or parenteral opoids.
Postoperative opoid
administration is associated with
side effects: nausea and
vomiting, respiratory depression,
pruritus and ileus. Analgesic
effects of parenteral opoids
usually pek within minutes of
administration. Maximal
respiratory depression with
morphine may occur until 20-30
min later.
Pain control
When an epidural catheter
is used, epidural bolus
administration of Fentanyl
(50-100mcq) or sufentanil
(20-30 mcq) with 5-10 ml
of 0,1% bupivacaine can
provide excellent pain
relief in adults.
Epidural morphine (3-5
mg) may also be used.
Nausea and vomiting
Postoperative nausea and vomiting (PONV) is common
following general anesthesia, occuring in 30% to 40% of all
patients.
The etiology of PONV is usually multifactorial and
associated with anesthetic and analgesic agents, the type
of surgical procedure and intrinsic patient factors such as
a history of motion sikness.
The greatest incidence seems to be in young women.
Nausea and vomiting
An increased incidence of nausea and vomiting is reported
following opioid administration and intraperitoneal
(especially laparoscopic), breast and strabismus surgery.
The greatest incidence seems to be in young women;
nausea may be more common during menstruation.
 Propofol anesthesia decreases the incidence of PONV and
a preoperative history of smoking decreases PONV.
APFEL SCORE for PONV
Postoperative nausea and vomiting
A scoring system that allocates one point for each of the four
risk factors is the Apfel score to try to stratify an individual
patient’s risk of PONV and guide prophylaxis. Patients who
score:
• 0 or 1 points have a low risk of PONV and should not routinely
receive antiemetics;
• 2 or more points have a high risk of PONV and should receive
combination therapy (use drugs with different modes of action).
For patients with two or more risk factors, consideration
should also be given to altering the anaesthetic technique to
one associated with a lower incidence of PONV, for example a
regional anaesthetic technique, general anaesthesia with total
intravenous anaesthesia (TIVA), avoiding opioids where
possible.
Postoperative nausea and vomiting
Therapy of PONV
Minimise patient movement.
Ensure analgesia is adequate.
Ensure good oxygenation and normal blood pressure.
Give IV fluids if dehydrated.
Administer anti-emetic early when patient is nauseated
rather than waiting for patient to vomit before treating
PONV
Post-operative opiates increase patient's risk of PONV so,
where possible, consider other analgesics.
Shivering and hypothermia
Shivering can occur in the PACU as a result of intraoperative
hypothermia or the effects of anesthetic agent.
The most important cause of hypothermia is a redistribution
of heat from the body core to the peripheral compartments.
A cool ambient operating room temperature, prolonged
exposure of a large wound, and the use of large amounts of
unwarmed intravenous fluids can also be contributory.
Other causes of shivering should be excluded, such as
bacteremia and sepsis, drug allergy or transfusion reaction.
Shivering and hypothermia
 Intense shivering causes
precipitous rises in oxygen
consumption, CO2 production
and cardiac output. These
physiological effects are often
poorly tolerated by patients
with preexisting cardiac or
pulmonary impairment.
Therapy
 Small iv doses of meperidine
(10-25 mg) can dramatically
reduce or even stop shivering.
 Hypothermia
 Hypothermia should be treated
with a forced-air warming
device, or less satisfactory with
warming lights or heating
blankets to raise body
temperature to normal.
Hypothermia has been
associated with an increased
incidence of myocardial
ischemia, arrhytmias, increased
transfusion requirements due to
coagulopathy and increased
duration of muscle relaxant
effects.
Agitation/delirium
Emergence delirium after anesthesia can be caused by a
variety of physiological and pharmacological factors.
Before any intervention is started to manage emergence
delirium, physiological causes must be investigated.
Arterial hypoxemia and hypercapnia are potential causes
of delirium or agitation after anesthesia.
 Hypoxemia, respiratory or metabolic acidosis or
hypotension, bladder distention or a surgical complication
must be considered in differential diagnosis of
postoperative agitation.
Agitation/delirium
 Therapy
 Treatment of emergence delirium generally involves treatment of the
signs and symptoms. Supplemental oxygen, fluid and electrolyte
replacement, and adequate analgesia may be appropriate. Medications
used for emergence delirium include benzodiazepines for calming if
the delirium is severe and antipsychotics, such as haloperidol and
physostigmine.
Respiratory complications
Respiratory complications
Respiratory problems are the most frequently and serious
complications in the PACU. Airway obstruction,
hypoventilation or hypoxemia are most commonly.
Airway obstruction in unconscious patients is due to the
tongue failing back against the posterior pharynx.
Other causes include laryngospasm, glottis edema,
secretions, vomitus, blood in the airway or external
pressure on the trachea (most commonly from a neck
hematoma).
Respiratory complications
 Paradoxical breathing is a
sign that breathing are not
properly. Near total or total
obstruction causes paradoxic
movement of the chest. The
abdomen and chest should
normally rise together during
inspiration;
 with airway obstruction the
chest descends as the abdomen
rises during each inspiration
Respiratory complications
Therapy
Patients with airway
obstruction should receive
supllemental oxygen. A
combined jaw-thrust and
head-tilt maneuever pulls
the tongue forward and
opens the airway and
insertion of an oral airway
often decrease the problem.
Laryngospasm
 Laryngospasm is the closure of
the vocal cords resulting in the
partial or complete loss of the
patient's airway.
 laryngospasm is a problematic
reflex which occurs often under
general anaesthesia. Spasm of
the vocal cords is more apt to
occur following airway trauma,
repeated instrumentation, or
stimulation from secretions or
blood in the airway
Laryngospasm
Therapy
The jaw-thrust maneuever,
particularly when combined with
gentle positive airway pressure via
a facemask usually breaks
laryngospasm. Insertion of oral
airway is also helpfull in ensuring a
patient airway down to the level of
the vocal cords. Any of secretion or
blood in the hypopharynx should
be suctioned to prevent recurrence.
Small dose of iv succinyl-choline
(10-20 mg) and positive pressure
ventilation with 100% oxygen.
Hypoventilation
 Hypoventilation is generally defined as a PaCO2> 45 mmHg.
Significant hypoventilation is usually clinically apparent when the
CO2> 60 mmHg or arterial blood pH<7,25.
 Signs are varied and include excessive somnolence, airway
obstruction, slow respiratory rate, tachypnea.
 Hypoventilation in the PACU is most commonly due to the residual
depressant effects of anesthetics on respiratory system, residual
muscle paralysis because inadequate reversal.
Hypoventilation
 Therapy
 Treatment should generally be directed at the underlying cause, but
marked hypoventilation always requires assisted or controlled
ventilation until causal factors are identified and corrected.
 Circulatory depression and severe acidosis are indications for
immediate and aggressive respiratory and hemodynamic intervention,
including airway and inotropic support as needed.
 Antagonism of opoid induced depression is provide with large doses
of naloxone.
Cardiovascular complications
 Hypotension
 Hypotension is usually due to
relative hypovolemia, left
ventricular dysfunction or arterial
vasodilatation. Absolute
hypovolemia can result from
inadequate intraoperative fluid
replacement, fluid sequestration
by tissues (third-spacing), wound
drainage or hemorrhage.
Significant hypotension is often
defined as a 20% to 30% reduction
in blood pressure below the
patient s baseline level and usually
requires correction
Cardiovascular complications
Therapy
Mild hypotension during recovery from anesthesia does
not require intensive treatment. Significant hypotension
requires correction. An increase in blood pressure
folowing a fluid bolus (250-500 ml crystaloid or 100-250 ml
colloid) generally confirms hypovolemia.
With severe hypotension a vasopressor or inotrope
(dopamine and epinefrine) may be necessary to increase
arterial blood pressure.
Cardiovascular complications
 Hypertension
 Postoperative hypertension
occurs within the first 30 min
and stimulation from incisional
pain, endotracheal intubation or
blooder distention is usually
responsible.
 Postoperative hypertension may
also reflect the neuroendocrine
stress response to surgery.
Cardiovascular complications
Therapy of postoperative hypertension
 Mild hypertension generally does not require treatment. Marked
hypertension can precipitate postoperative bleeding, myocardial
ischemia, heart failure or intracranial hemorrhage.
 In general, elevations in blood pressure greater than 20% to 30% of
the patient s baseline or those associated with adverse effects such as
myocardial ischemia, heart failure or bleeding should be treated.
 Marked hypertension should be treated with an iv infusion of
nitropruside, nitroglycerin or nicardipine.
Discharge criteria
 Before discharge, patients should have been observed for respiratory
depression for at least 20-30 min after the last dose of parenteral
opioid. Other minimum discharge criteria for patients recovering
from general anesthesia usually include the following:
 1. Easy arousability
 2. Full orientation
 3. The ability to maintain and protect the airway
 4. Stable vital signs for at least 15-30 min
 5. The ability to call for help, if necessary
 6. No obvious surgical complications (such as active bleeding)
Postanesthetic Aldrete recovery score
Complications during general anestehsia
Aspiration of gastric contents
Despite a seemingly appropriate preoperative fasting period, or
despite taking all of the precautions outlined above for patients
identified as at risk, occasionally regurgitation and aspiration
still occur. Signs suggesting aspiration include:
• coughing during induction or recovery from anaesthesia, or
during anaesthesia using a supraglottic airway device;
• gastric contents in the pharynx at laryngoscopy, or around the
edge of the facemask;
• if severe, progressive hypoxia, bronchospasm and respiratory
obstruction.
Occasionally, aspiration may go completely unnoticed during
anaesthesia, with the development of hypoxia, hypotension and
respiratory failure postoperatively
Complications during general anesthesia
 Aspiration of solid matter can cause hypoxia by physical obstruction,
whereas aspiration of acidic gastric fluid can cause a pneumonitis with
the syndrome of progressive dyspnoea, hypoxia, bronchial wheeze and
patchy collapse, consolidation on chest X-ray or all.
 The risk of mortality and serious morbidity increases with bronchial
exposure to greater volumes and acidity of aspirated material.
 Mendelson described the potential consequences of abolished airway
reflexes under anaesthesia and the subsequent aspiration of gastric
contents, which became synonymous with Mendelson's syndrome.
Complications during general anesthesia
 Draft algorithm for the management of vomiting after
induction:
 CALL FOR HELP→
 Head-down tilt, suctioning including use of suction catheters, apply
cricoid pressure, rapid sequence induction (RSI) if not paralysed, 100%
O2→
 Can intubate
 Intubation and suction down ETT before ventilation→
 Bronchoscopy. Bronchodilators. Antibiotics—no evidence. Steroids—
no evidence. ITU, Protective ventilation strategy.
 Cannot intubate
 Proseal LMA. Surgical airway.
Complications during general anesthesia
There is no place for routine administration of large‐dose
steroids.
Antibiotics should be given according to local protocols.
In those patients with bronchospasm resistant to
treatment, or with persistent hypoxia or hypotension,
surgery should be postponed unless it is potentially life
saving.
 Instead, the patient should be transferred to the ICU for
ventilation, with additional, invasive cardiorespiratory
monitoring as needed.
Complications during anaesthesia
 Anaphylaxis
 Anaphylaxis is a severe, life‐threatening generalized or systemic
hypersensitivity reaction.
 Most adverse drug reactions in anesthesia are mild and transient, consisting
mainly of localized urticaria as a result of cutaneous histamine release.
 The incidence of anaphylaxis caused by anaesthetic drugs is between 1:10 000
and 1:20 000 drug dosages, and is more common in females.
 Anaphylaxis involves the degranulation of mast cells and basophils, as the
result of either an allergic (IgE mediated) or non‐allergic (non‐IgE mediated)
reaction, liberating histamine, 5‐hydroxytryptamine (5‐HT) and associated
vasoactive substances.
Complications during anaesthesia
Anaphylaxis simptoms (clinical features) include:
• severe hypotension;
• severe bronchospasm;
• skin changes – erythema, urticaria;
• angio‐oedema, which may involve the airway;
• pruritus, nausea and vomiting;
• hypoxaemia.
Complications during anaesthesia
Anaphylaxis simptoms
Cardiovascular collapse is the most common and severe
feature.
Asthmatics often develop bronchospasm that is resistant
to treatment and are at a greater risk of death, especially
when the asthma is poorly controlled or there is a delay in
treatment.
Any circumstance that reduces the patient’s
catecholamine response (such as beta‐blockers, spinal
anaesthesia) will increase the severity.
Complication during anaesthesia
 Causes of allergic reactions
 During anaesthesia the commonest triggers are as follows.
 • Anaesthetic drugs: ◦ muscle relaxants (~60%): suxamethonium,
rocuronium, atracurium, vecuronium;
 ◦ induction agents (5%): thiopentone, propofol.
 • Latex (20%).
 • Antibiotics (15%): ◦ penicillin (70% of all antibiotic‐related
anaphylaxis); ◦ <1% of penicillin‐allergic patients may crossreact to
modern cephalosporins.
 • Intravenous fluids: colloids (3%).
 • Opioids (2%).
Complications during anaesthesia
 Therapy of anaphylaxis
 Discontinue all drugs likely to have triggered the reaction.
 • Maintain a patent airway, give high‐flow oxygen.
 • Elevate the patient’s legs providing ventilation is not compromised.
 Antihistamines: chlorpheniramine (H1 blocker) 10–20 mg slowly IV or
IM. There is no evidence for the use of H2 blockers.
 • Steroids: hydrocortisone 200 mg slowly IV or IM. This helps to
reduce late sequelae.
 • Bronchodilators: salbutamol, 2.5–5.0 mg nebulized or 0.25 mg IV.
Complication during anaesthesia
 Therapy of anaphylaxis
 Adrenaline, 50 μg slowly intravenously (0.5 mL of 1:10 000) under ECG
control. Dilution of adrenaline to 1:100 000 (10 μg/mL) allows better
titration and reduces the risk of adverse effects.
 If no ECG available, Adrenalin 0.5 mg intramuscularly (0.5 mL of
1:1000). If there is no improvement within 5 minutes, a further dose.
 Ventilation: intubation will be required if spontaneous ventilation is
inadequate or in the presence of severe bronchospasm. This may be
exceedingly difficult in the presence of severe laryngeal oedema. In
these circumstances a needle cricothyroidotomy or surgical airway
will be required.
Complications during anaesthesia
 Therapy of anaphylaxis
 Support the circulation: rapid IV infusion of fluids 10–20 mL/kg.
Crystalloids initially may be safer than colloids. In the absence of a
major pulse, it should start cardiopulmonary resuscitation using the
appropriate protocol.
 • Monitoring:
 ◦ ECG, SpO2, blood pressure, end‐tidal CO2. Establish an arterial line
and check the blood gases:
 ◦ monitor CVP and urine output to assess adequacy of circulating
volume.
Complications during anaesthesia
As soon as possible, these patients should be transferred
to an ICU for further treatment and monitoring. Reactions
vary in severity, can be biphasic, delayed in onset
(particularly latex sensitivity) and prolonged.
An infusion of adrenaline may be required.
The possibility of a tension pneumothorax (secondary to
barotrauma) causing hypotension must not be forgotten.
Complications during general anesthesia
 Malignant hyperpyrexia (hyperthermia)
 Malignant hyperpyrexia (MH) is a rare, inherited disorder of skeletal
muscle metabolism due to the presence of an abnormality in the
ryanodine receptor in the sarcoplasmic reticulum, which results in the
release of abnormally high concentrations of calcium causing
increased muscle activity and metabolism.
 Excess heat production causes a rise in core temperature of at least 2
°C/hour. It is triggered by exposure to any of the inhalational
anaesthetic drugs. For many years, suxamethonium was also
considered to be a potent trigger, but recently this has been called
into question.
 The incidence is between 1:10 000 and 1:40 000 anaesthetized patients.
Complications during anaesthesia
Malignant hyperpyrexia (hyperthermia)
Presentation
An unexplained:
◦ increase in end‐tidal CO2;
◦ tachycardia;
◦ increase in oxygen requirement (a falling SpO2 despite
increased inspired oxygen concentration).
A progressive rise in body temperature (this may be a late sign).
Tachypnoea in spontaneously breathing patients.
Muscle rigidity, especially persistent masseter spasm after
suxamethonium.
Complications during anaesthesia
 Malignant hyperpyrexia immediate management and therapy
 • Stop all volatile anaesthetic drugs, maintain anaesthesia with a total
intravenous technique.
 • It should change the anaesthesia circuits and soda lime and hyperventilate
with 100% oxygen.
 • Use a high fresh gas flow to flush the inhalational anaesthetic from the
patient and machine.
 • Maintain or start muscle relaxation with a nondepolarizing neuromuscular
blocking drug.
 • Terminate surgery as soon as practical.
 • Give dantrolene 2–3 mg/kg IV, then 1 mg/kg boluses as required (up to 10
mg/kg may be needed).
 • Start active cooling: ◦ cold 0.9% saline IV; ◦ surface cooling – ice over axillary
and femoral arteries, wet sponging and fanning to encourage cooling by
evaporation;
Complications during anaesthesia
Malignant hyperpyrexia immediate management and therapy
 Treat acidosis with 8.4% sodium bicarbonate 50 mmol (50 mL) IV
titrated to acid–base results.
 • Treat hyperkalaemia.
 • Transfer the patient to the intensive therapy unit (ITU) as soon as
possible for: ◦ temperature monitoring; may be labile for up to 48 hours;
◦ continuation of dantrolene to alleviate muscle rigidity; ◦ monitoring of
urine output for myoglobin and treatment to prevent renal failure; ◦
monitoring for and treatment of coagulopathy.
 Dantrolene
 This is the only specific treatment for MH. It inhibits calcium release,
preventing further muscle activity. Dantrolene is supplied in vials
containing 20 mg (plus 3 g mannitol), requires 60 mL water for
reconstitution and is very slow to dissolve
Complications during anaesthesia
Investigation of the family
Following an episode, the patient and their family
should be referred to a MH unit for investigation of
their susceptibility to MH.
Complications during anaesthesia
Anaesthesia for malignant hyperpyrexia‐susceptible
patients
• Employ a regional technique using plain bupivacaine if
appropriate.
• General anaesthesia: ◦ remove vaporizers from the anaesthetic
machine; ◦ use new circuits, hoses and soda lime; ◦ flush the
machine with high oxygen flow prior to use;
◦ use total intravenous anaesthesia (TIVA); an infusion of
propofol and remifentanil and oxygen‐enriched air for
ventilation;
◦ consider pretreatment with dantrolene (orally or IV) in those
who have survived a previous episode; ◦ monitor temperature,
ensure cooling available.