RECOVERY ROOMCARE

BYRAJEEV KUMAR

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.

DESIGN

◦Continous oxygen supply◦Laryngoscope ◦Ambu bag◦ETT◦Suction ◦Airways – oral - nasopharyngeal

EQUIPMENTS

PACU should contain all essential monitors like◦pulse oximetry◦ECG◦Capnograpry◦Temperature monitoring◦NIBP

MONITORS

Should have, Large doors Adequate lightning Sufficient electrical and plumbing facilities Efficient environmental control Central nursing station and physician

station Storage and utility room

FACILITIES

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

PACU STANDARDS

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 G.A.

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

Emergance from inhalational 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.

Emergence from IV agent

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

DELAYED EMERGENCE

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.

Tretment of delayed emergance

This period is usually complicated by lack of- adequate monitor. emergency drugs resuscitative equipmentPateint 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

Transport from operative room

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

1. RESPIRATORY COMPLICATION- airway obstruction and hypovenilation2 CIRCULATORY COMPLICATION- hypotention , hypertension, arrythmia3 FAILURE TO REGAIN CONCIOUSNESS4 NAUSEA AND VOMTING 5 HYPOTHERMIA & SHIVERING6 POSTOPERATIVE PAIN

COMPLICATONS IN RECOVERY ROOM

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

MANEGMENT OF COMPLICATIONS

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

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

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

Treatment of hypotension

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

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.

Treatment of postoperative hypertension

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)

ARRHYTHMIAS

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

Postoperative nausea and vomiting(PONV)

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

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.

POSTOPERATIVE PAIN

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 score

Staffview

Patient’s view Action

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 and tolerable; no reasonto seek (additional) treatment

Continue current therapy, review regularly

2 Moderate

Unpleasant situation; treatment desirable butnot necessarily at the expense of severetreatment side-effects

Continue current therapy, consider additional regular simple analgesia, e.g. paracetamol and/or NSAIDS

3 Severe Intolerable situation—will consider evenunpleasant treatments to reduce pain

Increase dose of opioid, or start opioid; consider alternative technique, e.g. epidural

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.

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

Patient controlled analgesia

Opioid Bolus dose Lockout time(min)

Infusion rate

Morphine 1-3 mg 10-20 0-1mg/hr

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

Fentanyl 15-25 microgram

10-20 0-50microgram/hr

Intravenous PCA

Hydromorphone 0.1-0.3mg 10-20 0-0.5mg/hr

Opioid Bolus dose Lockout time(min)

Infusion rate

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

Fentanyl 20-30 microgram

15 25-50 microgram/hr

Hydromorphone 0.15 microgram 30 0.1-0.2 microgram/hr

Epidural PCA

Cry Not crying Score 0

Crying Score 1

Posture Relaxed Score 0

Tense Score 1

Tense Relaxedor happy

Score 0

Distressed Score 1

Response Responds whenspoken to

Score 0

No response Score 1

Pain assessment for children under four years

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

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

DISCHARGE

Consciousness2 = Fully awake1 = Responds to name0 = No response

Activity on command2 = Moves all extremities1 = Moves two extremities0 = No movement

Respiration2 = Free deep breathing1 = Dyspneic, hyperventilating, obstructed breathing0 = Apneic

Modified Aldrete Score (Postanesthesia Recovery Score)

Circulation2 = Blood pressure within 20% of pre-op level1 = Blood pressure within 50%–20% of pre-op level0 = Blood pressure 50%, or less, of pre-op level

Oxygen saturation2 = SpO2 >92% on room air1 = Supplemental O2 required to maintain SpO2 >92%0 = SpO 2 <92% with O2 supplementation

Total Score is 10, minimum 9 is required fordischarge.

1. Vital Signs 2=within 20% of preoperative value 1=20% to 40% of preoperative value 0=40% of preoperative value2. Activity, mental status 2=Orientated and steady gait 1=Orientated or steady gait 0=Neither3. Pain 2=minimal 1=moderate 0=severe

Post Anaesthesia Discharge Scoring System (PADS)

4. Surgical bleeding 2=minimal 1=moderate 0=severe5. nausea and vomiting 2=minimal 1=moderate 0=severe

Maximum score = 10, patients scoring 9 are fit for discharge

Fast trackingBy 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 vomitingEach of this criteria is having score 0, 1, 2.The total score over 12 with no individual

score <1 is required for fast tracking.