Aims and objectives of Post anaesthetic care and management of complications DR. AFTAB
Transcript
1. DR. AFTAB
2. Introduction Recovery from general anesthesia is a time of
great physiological stress for many patients. Emergence from
general anaesthesia should ideally be smooth and gradual awakening
in a control environment. It often begins in the operating room or
during transport to the recovery room and frequently characterized
by complications. Even patients receiving spinal or epidural
anaesthesia can experience marked decrease in blood pressure during
transport. 2
3. The Standards for Postanesthesia Care I. All patients who
have received general anesthesia, regional anesthesia or monitored
anesthesia care shall receive appropriate post anesthesia
management. II. A patient transported to the PACU shall be
accompanied by a member of the anesthesia care team who is
knowledgeable about the patient's condition. The patient shall be
continually evaluated and treated during transport with monitoring
and support appropriate to the patient's condition. 3
4. III. Upon arrival in the PACU, the patient shall be re-
evaluated and a verbal report provided to the responsible PACU
nurse by the anesthesia care team who accompanies the patient. IV.
The patient's condition shall be evaluated continually in the PACU.
The patient shall be observed and monitored by methods appropriate
to the patient's medical condition. Particular attention should be
given to monitoring oxygenation, ventilation, circulation, level of
consciousness and temperature. V. Anaesthesiologist is responsible
for the discharge of the patient from the postanesthesia care unit
4
5. History of the PACU Methods of anesthesia have been
available for more than 160 years, the PACU has only been common
for the past 50 years. 1920s and 30s: several PACUs opened in the
US and abroad. It was not until after WW II that the number of
PACUs increased significantly. This was do to the shortage of
nurses in the US. In 1947 a study was released which showed that
over an 11 year period, nearly half of the deaths that occurred
during the first 24 hours after surgery were preventable. 1949:
having a PACU was considered a standard of care. 5
6. PACU Staffing One nurse to one patient for the first 15
minutes of recovery. Then one nurse for every two patients. The
anesthesiologist responsible for managing the patient in the PACU.
6
7. PACU Location Should be located close to the operating
suite. Immediate access to x-ray, blood bank, blood gas and
clinical labs. Should have 1.5 PACU beds per operating room used.
An open ward is optimal for patient observation, with at least one
isolation room. Central nursing station. Piped in oxygen, air, and
vacuum for suction. Requires good ventilation. 7
8. PACU in ideal set up 8
9. PACU Equipments Automated BP, pulse ox, EKG, and intravenous
supports should be located at each bed. Area for charting, bed-side
supply storage, suction, and oxygen flow meter at each bed-side.
Capability for arterial and CVP monitoring. Supply of immediately
available emergency equipment. Crash cart. Defibrillator. 9
10. Admission Report Preoperative history Intra-operative
factors : Procedure Type of anesthesia U/O Assessment and report of
current status Post-operative instructions 10
11. ROUTINE RECOVERY General Anesthesia Airway patency, vital
signs, and oxygenation should be checked immediately on arrival.
Subsequent B.P, P.R , and R.R measurements are routinely made at
least every 5 min for 15 min or until stable, and every 15 min
thereafter. Pulse oximetry should be monitored continuously in all
patients recovering from general anesthesia, until they regain
consciousness. 11
12. Neuromuscular function should be assessed clinically, eg,
head-lift. At least one temperature measurement should also be
obtained. Additional monitoring includes pain assessment (eg,
numerical or descriptive scales), the presence or absence of nausea
or vomiting, and fluid input and output including urine flow,
drainage, and bleeding. 12
13. All patients recovering from general anesthesia should
receive 3040% oxygen during emergence because transient hypoxemia
can develop even in healthy patients. Patients at increased risk
for hypoxemia, should continue to be monitored with a pulse
oximeter even after emergence and may need oxygen supplementation
for longer periods. Arterial blood gas measurements can be obtained
to confirm abnormal oximetry readings. 13
14. Oxygen therapy should be controlled in patients of COPD or
history of CO2 retention. Patients should generally be nursed in
the head-up position whenever possible to optimize oxygenation.
Deep breathing and coughing should be encouraged periodically.
14
15. Regional Anesthesia Pt. heavily sedated or hemodynamically
unstable following regional anesthesia should also receive
supplemental oxygen in the PACU. Sensory and motor levels should be
periodically recorded following regional anesthesia Precautions in
the form of padding or repeated warning may be necessary to prevent
self-injury from uncoordinated arm movements following brachial
plexus blocks. 15
16. Blood pressure should be closely monitored following spinal
and epidural anesthesia. Bladder catheterization may be necessary
in patients who have had spinal or epidural anesthesia for longer
than 4 h. 16
18. (1)Pain Post-operative pain management should be an
essential and integral part of the care given to the patient. A
major postoperative pain is defined as the pain that could endanger
life if inadequately relieved, and for which more vigorous and
effectives treatments may be justified although carrying risk.
18
19. In day care surgery, inadequate treatment of pain from a
relatively trivial insult may cause an unplanned hospital
admission. In hand surgery, inadequate treatment of pain may hinder
mobilization function. After Caesarean section, a mothers pain may
prejudice the bonding with her newborn child. 19
20. Postoperative pain management options 1)Cognitive
behavioral interventions: such as relaxation, distraction, ; these
can be taught preoperatively & can reduce pain, anxiety, &
the amount of drugs needed for pain control. 2)Systemic
administration of nonsteroidal anti- inflammatory drugs (NSAIDs) or
opioids using the traditional as needed schedule or
around-the-clock administration 3)Patient controlled analgesia
(PCA), usually meaning self-medication with intravenous doses of an
opioid; this can include other classes of drugs administered orally
or by other routes. 20
21. 4)Spinal or Epidural analgesia, usually by means of an
epidural opioid and/or local anaesthetic injected intermittently or
infused continuously. 5)Intermittent or continuous local neural
blockade (examples of the former include intercostal nerve blockade
with local anaesthetic or cryoprobe; the latter includes infusion
of local anaesthetic through an interpleural catheter) 6) Physical
agents such as massage or application of heat or cold.
7)Electroanalgesia such as transcutaneous electrical nerve
stimulation (TENS) 21
22. Intravenous Patient-Controlled Analgesia Intravenous
patient-controlled analgesia (PCA) optimizes delivery of analgesic
opioids and minimizes the effects of pharmacokinetic and
pharmacodynamic variability in individual patients. A PCA device
can be programmed for several variables, including the demand
(bolus) dose, lockout interval, and background infusion. 22
23. A lockout interval that is too long may result in
inadequate analgesia and decrease the effectiveness of intravenous
PCA. Too short Lockout Interval-Repeated dosing- Undesirable side
effect. most intervals range from 5 to 10 minutes, depending on the
medication in the PCA pump. 23
25. Ketamine Traditionally recognized as an intraoperative
anesthetic agent Its used for postoperative analgesia has increased
because of its NMDA-antagonistic properties, which may be important
in attenuating central sensitization and opioid tolerance.
Perioperative ketamine reduced 24-hour PCA morphine consumption and
postoperative nausea or vomiting and had minimal adverse effects.
25
26. Regional Analgesic Techniques Neuraxial (primarily
epidural) and peripheral regional analgesic techniques may be used
for the effective treatment of postoperative pain. In general, the
analgesia provided by epidural and peripheral techniques
(particularly when local anesthetics are used) is superior to that
with systemic opioids. use of these techniques may even reduce
morbidity and mortality. 26
27. Properties of neuraxial opoids 27
28. Doses of neuraxial opoids 28
29. Patient-Controlled Epidural Analgesia PCEA is a safe and
effective technique for postoperative analgesia on routine surgical
wards. Like intravenous PCA, PCEA allows individualization of
postoperative analgesic requirements and may have several
advantages over CEI. Background infusion in addition to the demand
dose is more common with PCEA than with intravenous PCA . 29
31. Peripheral Regional Analgesia Peripheral regional analgesic
techniques as a single injection or continuous infusion can provide
analgesia superior to that with systemic opioids. Wound
infiltration and peripheral regional techniques (e.g., brachial
plexus, lumbar plexus, femoral, sciatic- popliteal, and scalp nerve
blocks) can be used to enhance postoperative analgesia. 31
32. (2)Nausea & Vomiting Postoperative nausea and vomiting
(PONV) are a common problem following general anesthesia, occurring
in 2030% of all patients. Moreover, PONV may occur only at home
within 24 hr of an uneventful discharge (postdischarge nausea and
vomiting) in a significant number of additional patients. From a
patients perspective PONV can be more problematic than
postoperative pain. 32
33. Risk factors for PONV Patients factor Anaesthetic
techniques Young age Female gender Large body habitus History of
prior PONV History of motion sickness General anaesthesia Opioids
Volatile anesthetics 33
34. Surgical factor Postoperative factor Strabismus surgery
Laproscopic surgery Ear surgery Orchidopexy Gynaecological
surgeries Tonsillectomy Postopertive pain Hypotension 34
35. 35
36. Commonly used antiemetic drugs 36
37. (3)Delirium Approximately 10% of adult patients over the
age of 50 who undergo elective surgery will experience some degree
of postoperative delirium within the first 5 postoperative days.
The most significant preoperative risk factors include advancing
age (>70 years) preoperative cognitive impairment, decreased
functional status alcohol abuse a previous history of delirium.
37
38. Intraoperative factors that are predictive of postoperative
delirium include 1.)surgical blood loss 2.) hematocrit less than
30% 3.)number of intraoperative blood transfusions. 38
39. Management of delirium High risk patient should be
identified before admission to PACU. Severely agitated patients
require restraints or additional personnel to avoid self-inflicted
injury. Elderly patients who are to undergo minor surgery should be
scheduled in an outpatient center. It minimize the incidence of
post op delirium. 39
40. Emergence Excitement A transient confusional state that is
associated with emergence from general anesthesia. Should be
differentiated from persistent postoperative delirium. Common in
children, with more than 30% experiencing agitation or delirium.
Usually occurs within the first 10 minutes of recovery but can have
onset later in children who are brought to the recovery room
asleep. 40
41. The peak age of emergence excitement in children is between
2 and 4 years. In children, emergence excitement is most frequently
associated with rapid wake up from inhalational anesthesia. most
often associated with sevoflurane and desflurane. 41
42. Preventative measures are reducing preoperative anxiety,
treating postoperative pain, and providing a stress-free
environment for recovery. Medications that have been used to
prevent and treat emergence agitation/delirium in children include
midazolam, clonidine, dexmedetomidine, fentanyl, ketorolac, and
physostigmine. 42
43. (4)Shivering & Hypothermia Can occur due to intra op
hypothermia or side effect of anaesthetic agents. Most important
cause redistribution of heat core to peripheral compartment. Cool
ambient temperature . Use of cold I.V fluids. Incidence related to
duration of surgery and use of volatile anaesthetic agents. 43
44. Management Forced air warming device. Exclude cause such as
bacteremia , sepsis ,allergy or transfusion rxn. Meperidine (10-25
mg) also shown to reduce shivering. 44
45. (5)Respiratory complications Most frequently encountered
serious complications in the PACU. Majority are related to 1.
airway obstruction 2. hypoventilation 3. hypoxemia. 45
46. Upper Airway Obstruction Loss of Pharyngeal Muscle Tone
Most frequent cause of airway obstruction in the immediate
postoperative period. Characterized by a paradoxical breathing
pattern. Can be relieved by jaw thrust maneuver or continuous
positive airway pressure (CPAP) applied via facemask (or both). In
selected patients, placement of an oral or nasal airway, laryngeal
mask airway, or endotracheal tube may be required. 46
47. Residual neuromuscular blockade Residual NM blockade is an
important cause of airway obstruction in PACU. Pharyngeal function
is not restored fully below a train of four ratio of 0.9 Clinically
5 second sustained head lift is a good indicator. (other signs grip
strength, tongue protrusion, the ability to lift the legs off the
bed) Ability to strongly appose incisor teeth against a tongue
depressor is a best sign. This maneuver correlates with an average
train-of-four ratio of 0.85 as opposed to 0.60 for the sustained
head lift. 47
48. Factors contributing to a prolonged NDMR block 48
49. Factors contributing to prolonged DMR blockade 49
50. Laryngospasm Sudden spasm of the vocal cords that
completely occludes the laryngeal opening. Typically occurs in the
transitional period when the extubated patient is emerging from
general anesthesia. Patients who arrive in the PACU asleep after
general anesthesia are also at risk for laryngospasm on awakening.
50
51. Chest wall retraction High pitch inspiratory stridor
Decreased breath sound Hypoxemia Jaw thrust with CPAP (up to 40 cm
H2O) is often sufficient stimulation to break the laryngospasm.
Skeletal muscle relaxation can be achieved with succinylcholine
(0.1 to 1.0 mg/kg IV or 4 mg/kg IM). 51
52. Edema or Hematoma Possible operative complication in
patients undergoing prolonged procedures in the prone or
Trendelenburg position. Surgical procedures on the tongue, pharynx,
and neck, including thyroidectomy, carotid endarterectomy, and
cervical spine procedures, can produce more localized tissue edema
or hematoma. 52
53. Evaluation of airway for tracheal extubation 1) After
deflating the endotracheal tube cuff proximal end of the
endotracheal tube is occluded . Patient is then asked to breathe
around the tube. . Good air movement suggests that the patient's
airway will remain patent after tracheal extubation. 2) measuring
the intrathoracic pressure required to produce a leak around the
endotracheal tube with the cuff deflated. 3)In volume controlled
ventillation expiratory tidal volume can be calculated before and
after cuff deflation. Patients who require reintubation generally
have a smaller leak. 53
54. Management Patients with airway obstruction should receive
supplemental oxygen A combined jaw-thrust and head-tilt maneuver
pulls the tongue forward and opens the airway. Insertion of an oral
or nasal airway also often alleviates the problem. Any secretions
or blood in the hypopharynx should be suctioned Postoperative wound
hematomas following head and neck, thyroid, and carotid procedures
can quickly compromise the airway; opening the wound immediately
relieves tracheal compression. 54
55. Mask-ventilation of a patient with severe upper airway
obstruction resulting from edema or hematoma may be difficult Ready
access to difficult airway equipments. Surgical backup for
performance of an emergency tracheostomy. Dexamethasone (0.5
mg/kg)or aerosolized racemic epinephrine (0.5 mL of a 2.25%
solution with 3 mL of normal saline) may be useful in some cases.
55
56. Obstructive Sleep Apnea Obstructive sleep apnea syndrome is
often an overlooked cause of airway obstruction in the PACU.
Patients with OSA are particularly prone to airway obstruction and
should not be extubated until they are fully awake and following
commands. Continuous regional anesthesia techniques should be used
to provide postoperative analgesia. In patient with OSA, plans
should be made preoperatively to provide CPAP in the immediate
postoperative period. 56
57. Hypoxemia in PACU Mild hypoxemia is common in patients
recovering from anesthesia unless supplemental oxygen is given
during emergence. The routine use of a pulse oximeter in the PACU
facilitates early detection. ABG measurements should be performed
to confirm the diagnosis and guide therapy. Clinically-
restlessness, tachycardia, or cardiac irritability (ventricular or
atrial). Obtundation, bradycardia, hypotension, and cardiac arrest
are late signs. 57
58. Factors contributing to postop hypoxemia 58
59. Alveolar Hypoventilation PaCO2 more than 45 mm of hg.
Hypoventilation Significant hypoventilation clinically -PaCO2 is
greater than 60 mm Hg or arterial blood pH is less than 7.25.
Prolonged somnolence, airway obstruction, slow respiratory rate,
tachypnea with shallow breathing, or labored breathing. Mild to
moderate respiratory acidosis causes tachycardia and hypertension
or cardiac irritability and even circulatory depression. 59
60. Even a patient with a normal lungs may become hypoxemic if
continue to hypoventilate while breathing room air. Management
Arterial hypoxemia secondary to hypercapnia can be reversed by the
administration of supplemental oxygen. External stimulation of the
patient to wakefulness. Pharmacologic reversal of opioid or
benzodiazepine effect or controlled mechanical ventilation of the
patient's lungs. 60
61. Pulmonary edema Pulmonary edema in the immediate
postoperative period is often cardiogenic in nature secondary to
intravascular volume overload or CHF. Less common cause includes
postobstructive pulmonary edema , sepsis and TRALI. 61
62. Postobstructive Pulmonary Edema Transudative edema produced
by the exaggerated negative intrathoracic pressure generated by an
inspiratory effort against a closed glottis. Muscular healthy
patients are at increased risk of postobstructive pulmonay edema.
Laryngospasm is the most common cause. 62
63. Arterial hypoxemia is usually manifested within 90 minutes
of the upper airway obstruction and is accompanied by bilateral
fluffy infiltrates on the chest radiograph. Treatment is supportive
and includes supplemental oxygen diuresis positive-pressure
ventilation 63
64. Supplemental Oxygen The choice of oxygen delivery system in
the PACU is determined by the degree of hypoxemia, the surgical
procedure, and patient compliance. Nasal cannula with bubble
humidifier with flow of 6 L/min provides FIO2 of approximately
0.44. The other methods are through Hudson mask, Face tent oxygen
or blow-by setups. 64
65. Transfusion-Related Lung Injury Pulmonary edema in the PACU
may include transfusion- related lung injury in any patient who
received blood products intraoperatively. Typically manifested
within 1 to 2 hours(maximum 6 hrs) after the transfusion of
plasma-containing blood products. The resulting noncardiogenic
pulmonary edema is often associated with fever and systemic
hypotension. 65
66. Diagnostic criteria for TRALI 66
67. 67
68. Management Treatment is supportive and includes
supplemental oxygen and drug-induced diuresis. Mechanical
ventilation may be needed to support hypoxemia and respiratory
failure. Vasopressors may be required to treat refractory
hypotension. 68
69. Noninvansive ventilation An effective alternative to
endotracheal intubation in the ICU setting. Noninvasive modes of
ventilation in the PACU must be guided by careful consideration
Contraindications hemodynamic instability life-threatening
arrhythmias altered mental status, high risk of aspiration,
inability to use nasal or facial mask (head and neck procedures)
refractory hypoxemia 69
70. Continuous Positive Airway Pressure 8% to 10% of patients
who undergo abdominal surgery subsequently require intubation and
mechanical ventilation in the PACU. The application of CPAP in this
setting can decrease hypoxemia due to atelectasis by recruiting
alveoli. Increases functional reserve capacity may also improve
pulmonary compliance. Application of CPAP in the PACU significantly
reduced the incidence of reintubation, pneumonia, respiratory
faliure, and sepsis. 70
71. (6)Hemodynamic Instability Hypertension Common in PACU and
usually within 30 min of arrival. Patients with a history of
essential hypertension are at greatest risk. Postoperative systemic
hypertension and tachycardia are associated with an increased risk
of unplanned critical care admission and a higher mortality .
71
72. Factors leading to postoperative hypertension 72
73. Management Mild hypertension generally does not require
treatment Marked hypertension can precipitate postoperative
bleeding, myocardial ischemia, heart failure, or intracranial
hemorrhage. Any reversible cause should be identified and treated.
Blood pressure greater than 2030% of the patient's normal baseline
or those associated with adverse effects should be treated. 73
74. Mild to moderate Hypertension should treated with
-adrenergic blocker such as labetalol, esmolol, or propranolol; or
calcium channel blocker or nitroglycerine patch. Severe
Hypertension should be treated with intravenous infusion of
nitroprusside, nitroglycerin, nicardipine, or fenoldopam . 74
75. Hypovolemia Most common cause of the shock during
perioperative period. 1. Ongoing third-space translocation of fluid
2. inadequate intraoperative fluid replacement 3. loss of
sympathetic nervous system tone. 4. Ongoing bleeding should be
ruled out. Patient should be managed with iv fluids, blood products
and vasopressor if required. 75
76. Causes of Systemic Hypotension 76
77. Distributive (Decreased Afterload) Physiologic
derangements, like iatrogenic sympathectomy, critical illness,
allergic reactions, and sepsis. Neuromuscular blocking drugs are
the most common cause of anaphylactic reactions in the operative
setting followed by latex allergy Epinephrine is the drug of choice
to treat hypotension secondary to an allergic reaction. If sepsis
is suspected it is managed with fluid resuscitation , vasopressors
and broad spectrum antibiotics. 77
78. Cardiogenic (Intrinsic Pump Failure) Cardiogenic causes of
include 1. myocardial ischemia and infarction 2. cardiomyopathy 3.
cardiac tamponade 4. cardiac dysrhythmias. In low-risk patients
(