9 the post anesthesia care unit
TRANSCRIPT
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Postanesthesia CareCare Unit
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Postanesthesia Care UnitPostanesthesia Care Unit(PACU)(PACU)
to provide close monitoring and care to patientsto provide close monitoring and care to patientsrecovering from anesthesia and sedation.recovering from anesthesia and sedation.
assuring safety to the transition betweenassuring safety to the transition betweenanesthesia and the fully awake state,anesthesia and the fully awake state,before patients are transferred tobefore patients are transferred tounmonitored general wards.unmonitored general wards.
The PACU is staffed by a dedicated team of anThe PACU is staffed by a dedicated team of an
anesthesiologist, nurses and aides.anesthesiologist, nurses and aides.
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LocationLocation
located close to the operating suitelocated close to the operating suite
good access to immediate radiology,good access to immediate radiology,
blood bank, blood gas, and other clinicalblood bank, blood gas, and other clinicallaboratory services.laboratory services.
near the ICUnear the ICU
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sizesize
determined by the surgical caseload ofdetermined by the surgical caseload ofthe institution.the institution.
Approximately 1.5 PACU beds perApproximately 1.5 PACU beds per
operating room utilizedoperating room utilized
An open ward is optimal for patientAn open ward is optimal for patient
observationobservation
at least one isolation roomat least one isolation room
A separate pediatric PACUA separate pediatric PACU
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FacilitiesFacilities
The ward itself should have largeThe ward itself should have largedoors, adequate lighting, efficientdoors, adequate lighting, efficientenvironmental control and sufficientenvironmental control and sufficientelectrical and plumbing facilities.electrical and plumbing facilities.
the bed spacesthe bed spaces central nursing station and physiciancentral nursing station and physician
stationstation storage and utility roomsstorage and utility rooms
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Each bed space should have piped-inEach bed space should have piped-in
oxygen, air and vacuum for suctionoxygen, air and vacuum for suction
(both intermittent pressure for gastric(both intermittent pressure for gastricsuction and high pressure for airwaysuction and high pressure for airway
and chest suction).and chest suction).
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Drugs and equipment for routine care (ODrugs and equipment for routine care (O22,,
suction, and monitors) and advancedsuction, and monitors) and advancedsupport (mechanical ventilators,support (mechanical ventilators,pressure transducers, infusionpressure transducers, infusionpumps, and crash cart) must bepumps, and crash cart) must be
readily available.readily available.A crash cart containingA crash cart containing
cardiopulmonary resuscitationcardiopulmonary resuscitationequipment and emergency drugsequipment and emergency drugs
should be available and fully stockedshould be available and fully stockedat all times.at all times.
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The postanesthesia care unit should be well lighted, spacious, and
equipped to deal with any possible postanesthetic emergency. A
central nursing and physician station is useful. Each bedside
should be fully equipped with air, oxygen and suction.
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PersonnelPersonnel
nursing ratio 1:3 (one nurse to everynursing ratio 1:3 (one nurse to everythree patients) or 1:2 or 2:1three patients) or 1:2 or 2:1
A charge nurse should oversee nursingA charge nurse should oversee nursing
care.care. Most PACUs are under the medicalMost PACUs are under the medical
direction of the anesthesia departmentdirection of the anesthesia department The anesthesiologist is usuallyThe anesthesiologist is usually
responsible for patient discharge to theresponsible for patient discharge to thepostsurgical ward, ICU or home.postsurgical ward, ICU or home.
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Admission to the PACUAdmission to the PACU
Transport from the OR is carriedTransport from the OR is carried
out under direct supervisionout under direct supervision
of the anesthetist.of the anesthetist.with the head of the bed elevatedwith the head of the bed elevated
or in the lateral decubitusor in the lateral decubitus
position, face maskposition, face mask..
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ReportReport the anesthesiologist should give thethe anesthesiologist should give the
nurse a full report of the eventsnurse a full report of the eventsduring surgery.during surgery.
This report should include theThis report should include thepatients name, age, surgicalpatients name, age, surgicalprocedure, medical problems,procedure, medical problems,preoperative medications, allergies,preoperative medications, allergies,anesthetic drugs and methods, fluidanesthetic drugs and methods, fluid
and blood replacement, blood loss,and blood replacement, blood loss,urinary output, gastric output, andurinary output, gastric output, andsurgical or anesthetic complicationssurgical or anesthetic complicationsencountered.encountered.
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Discharge ConsiderationsDischarge Considerations
Before discharge, the patient who hasBefore discharge, the patient who hasundergone general anesthesia should beundergone general anesthesia should bearousable and oriented, have stable vitalarousable and oriented, have stable vitalsigns for at least the prior hour and besigns for at least the prior hour and be
comfortable.comfortable. Patients who have had recent large dosesPatients who have had recent large doses
of narcotic analgesics should be observedof narcotic analgesics should be observedfor at least 30 minutes.for at least 30 minutes.
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The patient should be able to obtainnursing help while in the surgical ward if
necessary.
Patients discharged withoutsupplemental oxygen need to have their
arterial oxygen saturation measured bypulse oximetry while they are breathingroom air.
Discharge of the patient from therecovery room following regionalanesthesia depends on the type of blockused and sedation administered.
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Uncomplicated regional blocks do notUncomplicated regional blocks do not
require recovery in the PACU.require recovery in the PACU.Postoperative monitoring is indicatedPostoperative monitoring is indicatedwhen heavy sedation was administered, awhen heavy sedation was administered, acomplication from the block occurredcomplication from the block occurred(e.g., intravascular injection of a local(e.g., intravascular injection of a local
anesthetic or pneumothorax), or whenanesthetic or pneumothorax), or whenrequired by the nature of the surgery.required by the nature of the surgery. A full description of the patients courseA full description of the patients course
should then be given by the recovery roomshould then be given by the recovery room
nurse to the ward nurse before the patientnurse to the ward nurse before the patientis transferred.is transferred.
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HemodynamicHemodynamic
complicationscomplications
HypotensionHypotension (4% of(4% ofadmissions)admissions) HypertensionHypertension (1% to 2%)(1% to 2%)
ArrhythmiasArrhythmias (4%)(4%) Myocardial ischemia andMyocardial ischemia and
infarctioninfarction
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HypotensionHypotensionInadequate venous returnInadequate venous return
b.b. True hypovolemia.True hypovolemia.Ongoing hemorrhage,Ongoing hemorrhage,inadequate fluid replacement, osmoticinadequate fluid replacement, osmoticpolyuria and fluid sequestrationpolyuria and fluid sequestration
c.c. Relative hypovolemiaRelative hypovolemia positive pressurepositive pressureventilation, intrinsic positive end-ventilation, intrinsic positive end-
expiratory pressure, pneumothorax,expiratory pressure, pneumothorax,pericardial tamponade.pericardial tamponade.
VasodilationVasodilation
Decreased inotropyDecreased inotropy
Myocardial ischemia and infarction,Myocardial ischemia and infarction,arrhythmias, congestive heart failure,arrhythmias, congestive heart failure,negative inotropic drugs, sepsis,negative inotropic drugs, sepsis,hypothyroidism, and malignanthypothyroidism, and malignanthyperthermiahyperthermia
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HypertensionHypertension
Etiology: preexisting hypertensiveEtiology: preexisting hypertensive
disease, pain, bladder distention,disease, pain, bladder distention,
fluid overload, hypoxemia, increasedfluid overload, hypoxemia, increased
intracranial pressure (ICP) andintracranial pressure (ICP) andadministration of vasoconstrictiveadministration of vasoconstrictive
agents.agents.
Hypertension may present withHypertension may present with
headache, visual disturbances,headache, visual disturbances,dyspnea, restlessness, and chestdyspnea, restlessness, and chest
pain, but is often asymptomatic.pain, but is often asymptomatic.
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Management aims at restoring bloodManagement aims at restoring bloodpressure close to what is normal for eachpressure close to what is normal for each
patient.patient. If needed, IV or sublingual drug.If needed, IV or sublingual drug.
3.3. Beta-adrenergic blockers:Labetalol,Beta-adrenergic blockers:Labetalol,propranolol and esmololpropranolol and esmolol
4.4. Calcium-channel blockers: Verapamil,Calcium-channel blockers: Verapamil,diltiazem, Nifedipinediltiazem, Nifedipine
5.5. HydralazineHydralazine
6.6. Nitrates: Nitroglycerin, Sodium nitroprussideNitrates: Nitroglycerin, Sodium nitroprusside
7.7. Alpha-adrenergic blockers: phentolamine,Alpha-adrenergic blockers: phentolamine,
labetalollabetalol
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Myocardial ischemia andMyocardial ischemia and
infarctioninfarctionT-wave changesT-wave changes
ST-segmentST-segment elevation or depression.elevation or depression.
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ArrhythmiasArrhythmias
Increased sympathetic outflow,Increased sympathetic outflow,hypoxemia, hypercarbia, electrolytehypoxemia, hypercarbia, electrolyteand acid-base imbalance,and acid-base imbalance,myocardial ischemia, increased ICP,myocardial ischemia, increased ICP,
drug toxicity, and malignantdrug toxicity, and malignanthyperthermia are possiblehyperthermia are possibleetiologies of perioperativeetiologies of perioperativearrhythmias.arrhythmias.
In the presence of more worrisomeIn the presence of more worrisome
rhythm disturbances, supplementalrhythm disturbances, supplementalOO22 should be delivered and propershould be delivered and proper
treatment begun while the etiologytreatment begun while the etiologyis investigated.is investigated.
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Respiratory complicationsRespiratory complications
HypoxemiaHypoxemia (0.9% of(0.9% of
admissions),admissions),
HypoventilationHypoventilation (0.2%)(0.2%)
Upper airway obstructionUpper airway obstruction
(0.2%)(0.2%)
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HypoxemiaHypoxemia
Causes of hypoxemia include theCauses of hypoxemia include thefollowing:following:
2.2. AtelectasisAtelectasis
3.3. HypoventilationHypoventilation4.4. Upper airway obstructionUpper airway obstruction
5.5. BronchospasmBronchospasm
6.6. Aspiration of gastric contentsAspiration of gastric contents
7.7. Pulmonary edemaPulmonary edema
8.8. PneumothoraxPneumothorax
9.9. Pulmonary embolismPulmonary embolism
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HypoventilationHypoventilation
Hypoventilation is an inappropriately low-Hypoventilation is an inappropriately low-minute ventilation and results inminute ventilation and results inhypercapnea and acute respiratoryhypercapnea and acute respiratoryacidosis. When severe, hypoventilationacidosis. When severe, hypoventilationproduces hypoxemia, COproduces hypoxemia, CO22 narcosis, andnarcosis, and
ultimately apnea.ultimately apnea.Etiologies of postoperative hypoventilationEtiologies of postoperative hypoventilation
may be divided in two groups:may be divided in two groups:n Decreased ventilatory driveDecreased ventilatory drive
n Pulmonary and respiratory musclePulmonary and respiratory muscleinsufficiencyinsufficiency
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Upper airway obstructionUpper airway obstruction
Principal signs are the lack of adequate airPrincipal signs are the lack of adequate airmovement, intercostal and suprasternalmovement, intercostal and suprasternalretractions, and discoordinateretractions, and discoordinateabdominal and chest wall motion duringabdominal and chest wall motion during
inspiration.inspiration.Common etiologies include:Common etiologies include:
3.3. Incomplete recoveryIncomplete recovery
4.4. LaryngospasmLaryngospasm
5.5. Airway edemaAirway edema6.6. Wound hematomaWound hematoma
7.7. Vocal cord (Vocal cord ( ) paralysis) paralysis
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Guidelines for extubationGuidelines for extubation
1.1. Adequate arterial PaOAdequate arterial PaO22..
2.2. Adequate breathing pattern.Adequate breathing pattern.
3.3. Adequate level of consciousness forAdequate level of consciousness forcooperation and airway protection.cooperation and airway protection.
4.4. Full recovery of muscle strength.Full recovery of muscle strength.
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Before proceeding with extubation, the
PACU anesthesiologist should be aware ofpreexistent airway problems in the eventthat reintubation is necessary.Supplemental O
2
is administered, the
endotracheal tube, mouth, and pharynxsuctioned, and the tube removedfollowing a positive-pressure breath.
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Renal complicationsRenal complications
OliguriaOliguria PolyuriaPolyuria Electrolyte disturbancesElectrolyte disturbances
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OliguriaOliguriaurine output less than 0.5 mL/kg per hour, buturine output less than 0.5 mL/kg per hour, but
common sense must be used.common sense must be used.
Hypovolemia is the most frequent cause ofHypovolemia is the most frequent cause ofpostoperative oliguria.postoperative oliguria.
The pre-, post-, and intra-renal causesThe pre-, post-, and intra-renal causes
4.4. Prerenal oliguria includes conditions thatPrerenal oliguria includes conditions that
decrease renal perfusion pressure. Besidesdecrease renal perfusion pressure. Besideshypovolemia, other causes of a decreasedhypovolemia, other causes of a decreasedcardiac output must be considered.cardiac output must be considered.
5.5. Intrarenal: acute tubular necrosis secondary toIntrarenal: acute tubular necrosis secondary tohypoperfusion (e.g., shock or sepsis), toxinshypoperfusion (e.g., shock or sepsis), toxins
(e.g., nephrotoxic drugs or myoglobinuria) and(e.g., nephrotoxic drugs or myoglobinuria) andtrauma.trauma.
6.6. Postrenal: urinary catheter obstruction, trauma,Postrenal: urinary catheter obstruction, trauma,and iatrogenic damage.and iatrogenic damage.
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PolyuriaPolyuriaurine output disproportionately high forurine output disproportionately high for
a given fluid intake.a given fluid intake.
2.2. Excessive volume administration.Excessive volume administration.
3.3. Pharmacologic diuresis.Pharmacologic diuresis.
4.4. Nonoliguric renal failure.Nonoliguric renal failure.5.5. Osmotic diuresis may be caused byOsmotic diuresis may be caused by
hyperglycemia, alcohol intoxication,hyperglycemia, alcohol intoxication,and administration of hypertonicand administration of hypertonicsaline, mannitol, or parenteralsaline, mannitol, or parenteralnutrition.nutrition.
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Electrolyte disturbancesElectrolyte disturbances
hyperkalemiahyperkalemia and acidemia.and acidemia.
HypokalemiaHypokalemia and alkalemiaand alkalemia
HypomagnesemiaHypomagnesemia
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Delayed awakeningDelayed awakening Neurologic damageNeurologic damage Emergence deliriumEmergence delirium Peripheral neurologic lesionsPeripheral neurologic lesions
Neurologic complicationsNeurologic complications
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Delayed awakeningDelayed awakening
2.2. The most frequent cause is theThe most frequent cause is thepersistent effect of anesthesia.persistent effect of anesthesia.
3.3. Decreased cerebral perfusionDecreased cerebral perfusion
4.4. Metabolic causes of delayedMetabolic causes of delayedawakening include hypoglycemia,awakening include hypoglycemia,sepsis, preexistingsepsis, preexistingencephalopathies, and electrolyteencephalopathies, and electrolyte
or acid-base derangements.or acid-base derangements.
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Emergence deliriumEmergence delirium
is characterized by excitement alternating withis characterized by excitement alternating withlethargylethargy , disorientation, and, disorientation, andinappropriate behavior.inappropriate behavior.
Delirium may more frequently occur in theDelirium may more frequently occur in the
elderly and in those with a history of drugelderly and in those with a history of drugdependency or psychiatric disorders.dependency or psychiatric disorders.
Many drugs used perioperatively may precipitateMany drugs used perioperatively may precipitatedelirium: ketamine, opioids,delirium: ketamine, opioids,
benzodiazepines, large doses of atropine.benzodiazepines, large doses of atropine.
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Delirium may be a symptom ofDelirium may be a symptom ofongoing pathology (e.g.,ongoing pathology (e.g.,hypoxemia, acidemia,hypoxemia, acidemia,hypoglycemia, intracranial injury,hypoglycemia, intracranial injury,sepsis, severe pain, and alcoholsepsis, severe pain, and alcoholwithdrawal).withdrawal).
Treatment is symptomatic:Treatment is symptomatic:supplemental Osupplemental O22, fluid and, fluid and
electrolyte replacement, andelectrolyte replacement, and
adequate analgesia. Anadequate analgesia. Anantipsychotic medication such asantipsychotic medication such ashaloperidol, Benzodiazepines mayhaloperidol, Benzodiazepines maybe added.be added.
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Peripheral neurologicPeripheral neurologic
lesionslesionsmay follow direct surgicalmay follow direct surgical
damage and improperdamage and improper
intraoperative positioning.intraoperative positioning.
Early neurological consultationEarly neurological consultation
for diagnosis andfor diagnosis and
rehabilitation are crucial for arehabilitation are crucial for afull recovery.full recovery.
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Principles of painPrinciples of pain
managementmanagement OpioidsOpioids NonsteroidalNonsteroidal Adjuvant analgesicsAdjuvant analgesics Regional sensory blocksRegional sensory blocks
Patient-controlledPatient-controlled
Principles of painPrinciples of pain
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Principles of painPrinciples of pain
managementmanagementAdequate analgesia begins in the OR and continuesAdequate analgesia begins in the OR and continues
in the PACU.in the PACU.
Opioids (IV or peridural) are the mainstay ofOpioids (IV or peridural) are the mainstay ofpostoperative analgesia. Intramuscularpostoperative analgesia. Intramuscularinjections, ordered on an as needed basis,injections, ordered on an as needed basis,
have essentially no indication in adult PACUhave essentially no indication in adult PACUpatients.patients.
Fentanyl, Morphine, MeperidineFentanyl, Morphine, Meperidine
Nonsteroidal anti-inflammatory drugs (NSAIDs):Nonsteroidal anti-inflammatory drugs (NSAIDs):Ketorolac,ibuprofen, acetaminophenKetorolac,ibuprofen, acetaminophen
Regional sensory blocksRegional sensory blocks
Patient-controlled and continuous epiduralPatient-controlled and continuous epiduralanalgesiaanalgesia
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Postoperative nausea andPostoperative nausea and
vomitingvomiting (PONV)(PONV)
PONV typically occurs in 20 to 30%PONV typically occurs in 20 to 30%of surgical cases.of surgical cases.
aspiration of emesis, gastricaspiration of emesis, gastricbleeding, and wound hematomasbleeding, and wound hematomasmay occur with protracted ormay occur with protracted orvigorous retching or vomiting.vigorous retching or vomiting.
Troublesome PONV can prolongTroublesome PONV can prolongrecovery room stay andrecovery room stay andhospitalization.hospitalization.
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Body temperatureBody temperature
changeschanges HypothermiaHypothermia
HyperthermiaHyperthermia
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ACUTEACUTE
POSTOPERATIVEPOSTOPERATIVE
PAIN MANAGEMENTPAIN MANAGEMENT
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Definition and HistoryDefinition and History
Acute pain: a normal, predicted, physiological response to an
adverse chemical, thermal or mechanical stimulus
-Surgery, trauma and acute illness
-Short duration, recent onset, poss. prolong or chronic
Consequences of surgical procedure
-Cardiopulmonary compression-Autonomic hyper-stimulation
-Increased blood clotting
-Water retention and delayed GI function
-Immune dysfunction
-Pain:
Surgical injuries and emotional reactions
Fear of pain (59%) and postponing surgery (8%)
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Definition and HistoryDefinition and History
Consequences of acute postop pain
-Increased M&M
Cardiovascular : HTN, ischemia, MI, arrhythmia, DVT
Pulmonary: atlectasis, pneumonia, bronchospasm
CNS: agitation, elevated ICP, strokeGI/GU: ileum, constipation, N/V, urinary
retention
Surgical site: poor healing, tissue breakdown, bleeding
-Prolonged hospital staying-High health care cost
-Chronic pain syndrome
-Negative physical and psychological effects
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Definition and History
Historically, postop pain mgt has been inadequately
-Patient education and communication
-Staff training/knowledge on acute pain management
-Pain assessment before and after analgesia-Timely evaluation and follow-up
Recently, more attention to the pain
-1992/ANA: comfort & pain relief in dying patient
-1995/APS: pain scale as the fifth vital sign
-2000/JCAHO: pain assess and mgt as a patients right
-2003/NPCPA: the decade of pain control and research
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Professional Guidelines for Pain Management
Agency/year Guideline
-ASA/95,04 Practice guidelines for acute pain managementin the perioperative setting
-APS/03 Principles of analgesic use in the treatment ofacute pain and cancer pain
-EAU/03 Guidelines on pain management
-VHADD/02 Clinical practice guideline for the managementof postoperative pain
-JCAHO/00 Pain assessment and management:
an organizational approach-AHCPR/93 Acute pain management
-IASP/92 Task force on acute pain
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Acute Pain Service Models
APS with Anesthesiologists and other care providers 24hr availability Personal training via up-to-date knowledge/skills/techniques
Multi-models with more aggressive ways Comprehensive techniques
New pharmacological agents Reliable assessment of pain
Pre/intra/postoperative evaluation Timely monitoring and management
Pain scale, response and adverse reactions to treatment
Life-threaten emergency
Outcome A score of 3 or below without adverse reactions Patients satisfied and early discharged
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Assessment of Pain & Management
Subjective report by patient-Pain score: 0-10 (no pain to worst pain in life)
-Satisfaction score
-Anxiety, fear, culture/religious influence, communication
Objective report by APS
-General condition
Vital signs, mental status
-Clinical functionsDeep breath, cough, ambulation
-Monitoring response to therapy and adverse reactions
P i P i E l i & Pl i
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Preoperative Patient Evaluation & Planning
Proactive individualized APS planningType of surgeryExpected severity of acute painPatients previous experience with pain
Type of analgesia (PO,IV,IM, PCA, epidural)
Response to the treatment
Any adverse reactions
Any surgical complicationsCo-existing conditions
Cardiac, pulmonary, renal, diabetic neuropathy,sickle cell anemia, mental status
Allergies and drugs (anticoagulation, pain pills)Risk-benefit ratio for the available techniques
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Type of Surgery & Severity of Pain
Minor Intermediate Major
Surgery Inguinal Hernia Fem/Hip ORIF Thoracotomy
Breast Biopsy Hysterectomy Nephrectomy
Varicose veins Exp. Lap ColectomyClosed reduction Lower abd. Upper abd.
Knee arthroscopy Maxillofacial TKR/THR
Gyn laparoscopy Cesarean section AAA
Pain mild-moderate moderate-severe very severe
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Preoperative Preparation of the Patient
Adjustment or continuation of medicationsWithdrawal syndrome
Surgical-related stress/physiological reactions
Optimizing patients conditions
Premedication prior to surgery Initiation of analgesic pain management program
Reduction of preexisting pain and anxiety
Patient and family educationBehavioral pain control techniques/communication
Emotional/stress relief and support
Optimal use of PCA and PCEA
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Intraoperative Evaluation & Management
Preemptive analgesia (Reducing sensitization)
-Local infiltration
-IV opioids
-Epidural bolus or continued infusion
Lower sympathetic tone
-SBp 20-30% below base-line
-HR 50-70s
Emergence or spontaneous breath
-RR is key (12-15/min)
-Adequate oxygenation and ventilation
P t ti E l ti & M t
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Postoperative Evaluation & Management
PACU
Rapid control pain score to 3-4 or below IV Toradol or PO weak opioid for mild pain IV bolus of Morphine for mod-severe pain Fontanels or combined Morphine for very severe pain Peripheral nerve blockade
Then continue multi-model pain management In-patient: PCA or PCEA
Epidural or PNB catheter
IV, IM or PO Out-patient: PO opioid, NSAIDs,
Durogenic patchFrequently Assessment of pain/satisfaction scale
Adjustment management
Treatment of adverse reactions
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Therapeutic Models for Acute Pain
Systemic opioids
-Enteral Oral (PO): via digestion, absorption, liver metabolism then to blood
Rectal, Sublingual (SL): directly into vein
-Parenteral
Transdermal/Transmucosal/Subcutaneous (SQ): slow absorption Intramuscular (IM): 15-30 min reach peak blood concentration
Intravenous (IV): bolus or infusion/PCA
Neuroaxial (intrathecal/epidural)
Afferent neural block with L.A. (+/- opioid)-Neuraxial (intrathecal or epidural)
-Peripheral plexus/nerve & incision
NSAIDs
Others
S t i O i id
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Systemic Opioids
-Type
Hydrophilic: Morphine, Hydromorphone, Meperidine Lipophilic: Sufentanil, Fentanyl
Mixed: DepoDur (liposome slow-release morphine)
-Enteral: Short-acting: Codeine, Hydrocodone, Oxycodone, Hydromorphone
Long-acting: MsContin, OxyContin, Methadone
Newer agents: Avinza, Kadian (longer-acting morphine)
-Parenteral: Short-acting: Fentanyl, Sufentanil, Remifentanil
Intermittent: Meperidine, Hydromorphone Long-acting: Morphine, Duromorphine
Transdermal: Duragesic patch (Fentanyl)
Transmucosal: ACTIQ (Fentanyl)
Th ti M d l f A t P i
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Therapeutic Models for Acute Pain
IV-PCA
-Potential efficacy for most in-house patients withmoderate to severe pain procedures
-Improving pain scores & patient satisfaction
-Equivocal to PCEA
-Better or more constant analgesia with basal infusion
Agents: bolus(mg) lockout(min) basal(mg/hr)
Morphine 0.5-3 5-10 0.5-1Hydromorphone 0.1-0.5 5-15 0.2-0.5
Meperidine 50-100 5-15 5-50Fentanyl 0.015-0.05 3-10 0.02-0.1
Methadone 0.5-3 10-20
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Therapeutic Models for Acute Pain
IV-PCA overdose Clinical symptom and sign Hypotension Asleep, drowsing, and seizure (Meperidine) Respiratory depression, apnea and death
Estimated death rate: 1in 10,000-30,000
Programming errors of PCA machine
Drug prep errors Error drug
Error concentration Basal infusion
Patient conditions and co-exited morbidities
Inadequate observation from care provider
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Therapeutic Models for Acute Pain
Inadequate IV-PCA Usually managed by non-anesthesiologists
Lack of understanding of adverse physiologic
squealer Myths about opioid risks persist
Addiction, dependence
Lack of application on multimodal therapyBolus or breakthroughRegional techniques
Analgesic gap in transition to oral route
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Therapeutic Models for Acute Pain
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Therapeutic Models for Acute Pain
Epidural analgesia with L.A.
-Local anesthetics Conc.(%) OnsetDuration Lidocaine 1-2 quick short
Mepivacaine 1-2 quick intermittent
Bupivacaine 0.1-0.125 (T) slow long
> Ropivacaine-Vasoconstrictor: Epinephrine, Phenylephrine
Lowing systemic absorption
Enhancing blockade and prolonging duration
Testing dose
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Pros and Cons of Neuraxial Analgesia
Advantages Improving postop pain control Reducing pulmonary complication & GI motility Reducing incidence of postop myocardial infarction (T>L) Reducing hypercoagulability & DVT (L.A.>opioid)
Better patients satisfaction/life-quality & early discharge Contraindications
Absolute RelativeNo consent/refuse Around area infection
Sepsis or bacteremia Demyelinating CNS diseases
Elevated ICP DementiaInfection at site Hypovolemia
L.A allergy LBP/Prior spinal surgery
Coagulopathy Drugs (ASA)
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Complications of Neuraxial Analgesia
-L.A. allergy & toxicity
Hypersensitivity: skin rashes to anaphylaxis
Toxic symptoms:
CV CNS
dysrhythmia circumoral numbness
bradycardia tinnitus, blurred visionhypotension agitation, confusion
asystole seizure
-Narcotics
Pruritus, ileum, urinary retention, N/V
Respiratory depression and apnea
Complications of Neuraxial Analgesia
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Complications of Neuraxial Analgesia-Headache
Spinal H/A, Co-existed H/A, Meningitis, Pneumocepheral
-Infections Epidural abscess, Arachnoiditis
Risk factor: Steroids dependent, Sepsis, Localized lesions
-Hematoma Blood tap or vascular injury
Anticoagulopathy:
-Drugs: Coumadine, Plavix, LMWH, ASA, Herbs
-Congenital disease: vw disease, hemophyllis
Prevention:-Stopping anticoagulators and rechecking coax profiles
5d for Coumadine, 12d for Plavix, 12hr for LMWH
-Correcting coagulopathy before giving/withdrawing
FFP, DDAVP, cryoprecipitate, specific factor(VIII)
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R i l A l i T h i
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Regional Analgesia Techniques
Peripheral nerve blocks (PNB) Intercostal, Interpleural Ilioinguinal and 3-in-1 block Plexus: Interscalene, Axillary, Brachial, Femoral, Ankle block Penile and dorsal nerve block
IV block: Bier Block Field infiltration
Intraartricular block (peripheral opoid receptor) 1-5 mg morphine +/- bupivacaine(0.25%)
Systemic absorptive rate:Intercostal>caudal/spinal>epidural>brachial plexus>SQ
Adjuvant (clonidine, epinephrine, opioids) Reducing L.A. dose with less motor block Improving analgesia
Regional Analgesia Techniques
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Regional Analgesia Techniques
Local anesthetics
Neural blockade sequence:Sympathetic block: temp. elevation/vasodilatationLoss of pain and temp. sensationLoss of proprioception, touch and pressure sensationMotor block
Agents Lido Mepiv Bupiv RopivConc.(%) 1-2 1 .25-.5 .2
Onset (min) 5-10 >10 10-15 10-15
Duration(min) 30-120 45-90 120-240 120-360
Max dose(mg) 300/500 300/500 175/225 200/Spinal/epidural +/+ -/+ +/+ -/+
PNB/infiltra. +/+ +/+ +/+ +/+
IVor 2%,epi >1% >.5% >.5%
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Regional Analgesia Techniques
-AdvantagesPatient satisfaction, fully function
Better & prolonged analgesia
Lower opioid consumption
Lower adverse reactions: opioid via L.A.
Early discharge
-Disadvantages
Experienced, high skillful providerDifficult position for certain blocks
Potential nerve injuries
Th ti M d l f A t P i
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Therapeutic Models for Acute Pain
NSAIDS
Inhibiting cyclooxygenase (COX), low prostaglandins COX-1 in various tissues with normal physiologic regulations COX-2 only induced by pain & inflammation COX-2 inhibitors (Vioxx, Celebrex):
Analgesia/anti-inflammation
No side effects of opioid, steroids and other NSAIDS (COX1&2)
Increase risk of AMI, CVA in patients with cardiovascular disease
Precautious PUD, GI or CNS hemorrhage; kidney, liver, or platelet dysfunction
Acetaminophen alone or combined with opioid Mild to moderate pain
Ketorolac (Toradol): only parenteral form Potent analgesia: 30 mg = 10mg morphine, same onset & duration Loading: 30-60 mg, then 15-30 mg q6h for up to 5 days
Therapeutic Models for Acute Pain
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Therapeutic Models for Acute Pain
Others-NMDA antagonist:
Reducing hyperalgesia, allodynia and chronic pain
Ketamine, Dextromethorphan, Methadone
Ketamine (.5-1mg/kg): preemptive analgesia & few side effects
-Alpha 2 agonist: Clonidine, Dexmetodomidine
Effective in reducing postoperative opioid requirements
-Physical therapy, behavior relaxants, TENS
-Specific: Adequate drainage of urine, bloody and fluids
Surgical re-exploration
M lti M d l T h i f P i M t
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Multi-Model Techniques for Pain Management
Most effective analgesic technique (single one)
-Afferent neural blockade with local anestheticsNeuroaxial (spinal or epidural) block
Peripheral nerve block
Local infiltration
-Intrathecal opioids
-Epidural opioids and clonidine
-PCA with opioids
-NSAIDS and other agents
Multi-drugs are more potent than single one
Multi-routes are more potent than single route
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Multimodal Techniques for Acute Pain Control
Two or more analgesic agents via a single agent-Epidural or intrathecal opioids combined with
L.A. via epidural opioid
L.A. via epidural L.A.
Clonidine via epidural opioid
-IV opioids combined with
Clonidine
KetorolacKetamine
-Oral opioid combined
NSAIDs, COXIBs, or acetaminophen
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Cost of Postoperative Pain Management
Cost of medications
Health care providers
-Physician
-Nurse
Cost of instruments & equipments
-PCA pump and tubes
-Epidural and spinal trays
-Peripheral nerve block kits
Length of hospitalization
Pain related complications
Outcomes
Ch ll f C h i APS
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Challenge of Comprehensive APS
-Increasing demands of anesthesiologistsAnesthesiologist shortage
Increased surgical loading
Patient population change
-Hospital staff shortage
-Financial LimitationLower or no reimbursement for IV-PCA
Lower reimbursement for continuous PNBsO.K. for Epidurals
-Malpractice risksEpidural, intrathecal > PNB > IV, IM, PO
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Thanks for your attention!Thanks for your attention!