Recovery From Anaesthesia

HOSAM M ATEF

Sanaa Farag WasfyLecturer of anaesthesia and

intensive care

* Recovery is a continual process, the

early stages of which overlap the end of

intraoperative care.

* Patients cannot be considered fully

recovered until they have returned to their

preoperative phsiological state.

The entire process may last many days

Divided into three phases :

1- Early recovering (awaking and recovery of vital

reflexes)

2- Intermediate recovery (immediate clinical

recovery and home readiness)

3- Late recovery(full recovery and psycholgical

recovery).

Early recovery commences on discontinuation of

anesthetic agent, which allows the patient to

awaken, recover protective airway reflexes, and

resume motor activity.

It traditionaly continues in postanesthsia care unit

(PACU).

Patients are likely to begin responding to verbal

stimuli when alveolar anesthetic concentrations

are decreased to about 0.5 MAC for the volatile

anesthetic drug (MAC awake) if unimpeded by

other factors.

Increased ventilation results in a more rapid decline

in alveolar anesthetic concentration which hastens

recovery, provided that the arterial carbon dioxide

pressure is not so low that it diminshes cerebral

blood flow and the removal of aneshetic agent from

the brain.

Recovery from neuromuscular blockade may be

monitored by peripheral nerve stimulation and by

clinical indices.

Recovery from intravenous opioids and hypnotics

may be more variable and difficult to quantify than

recovery from inhalation and neuromuscular

blocking agents.

Transport from the operating room is usually complicated

by the lack of adequate monitors, access to drugs, or

resuscitative equipment.

Patients should not leave the operating room unless they

have a stable and patent airway, have adequate

ventilation and oxygenation, and are hemodynamically

stable.

All patients should be taken to the PACU on a bed that can

be placed in either the head down or head up position.

Transport

The PACU should be located near the operating

rooms. A central location in the operating room

area, Proximity to radiographic, laboratory, and

other intensive care facilities on the same floor is

also highly desirable.

A ratio of 1.5 beds per operating room is customary.

Every effort should be made to diminish

unnecessary noise in PACU.

PACU

The PACU should be staffed only by nurses specifically

trained in the care of patients emerging from anesthesia.

They should have expertise in airway management and

advanced cardiac life support as well as problems commonly

encountered in surgical patients relating to wound care,

drainage catheters, and post operative bleeding.

The nurse-to-patient ratio is 1:1 for sick patients and 1:2 or

1:3 for routine cases.

Vital signs should be recorded at least every 15

minutes and recorded on a separate sheet. The

patient is encouraged by the nurse to cough,

breathe deeply, and change body position.

Monitoring

The most important monitor is a well informed and

skilled person; with immediate access to

anaesthetic assistance. Technical support is

important but sophisticated electronic monitors are

not universally essential

1) Pain.

2) PONV.

3) Agitation.

4) Croup.

5) Sore-throat.

6) Headache.

7) Shivering.

8) Increased body temperature.

9) Cardiovascular.

10) Respiratory.

Postanaesthesia care problems

Scores determines when patients are fit for

discharge from PACU, various criteria for readiness

for discharge from PACUs have been established.

The modified Aldrete score is the most common

system used. A score> or = 9 is required for

discharge.

.

Discharge

Postaesthesia discharge scoring system(PADSS)

determines home readiness and the optimal length

a patient stays after day-case surgery.

Scoring system must be practical, simple, easy to

remember, and not place additional burden on

personnel

It is the ability to transfer suitably recovered patients

from the OR directly to the phase II recovery area, by

passing the most costly PACU.

Children derive an additional benefit from fast

tracking in that they are more quickly reunited with

their parents.

Fast track recovery

To institute successful fast tracking programs, it is

necessary to modify anesthetic techniques and to

use the newer shorter acting anesthetics,

narcotics and muscle relaxants.

Modified aldretes scoring system may not be

adequate after day case procedures because it fails

to consider common side effects as pain nausea

and vomiting, therefore a new fast track scoring

system that incorporates both has been proposed.

It is delayed return of level of conscious.

There are several causes:

metabolic and electrolytes.

Cerebral hypoperfusion.

Cerebral depression by drugs.

Delayed recovery

Delayed recovery of sensory or motor may occur

after regional or neuroaxial block

Delayed recovery of consciousness , vital and

cognitive functions may occur after general

anesthesia

Over dose iv anesth ,inhalational, opioid

Benzodiazepines , sedative

NMB

Antihistaminic ,alcohol ,street drugs

Antiepileptic ,cimetidine , tranquilizers ,

antipsychotic

Antidepressant , analgesics , addiction

Drugs

Hypothermia , hyperthermia , hypotension , hypertension ,

hypoxia , hypercarbia

Pediatric, geriatric, prolonged surgery

Anxiety ,pain ,apprehension , acidosis ,alkalosis

Organ failure

( cardiovascular ,respiratory ,renal ,neuromuscular ,endocrina

l ,liver )

Genetic diseases

metabolic

Anoxia ,TBI , embolic ,hemorrhagic , epileptic

Mental retardation

Hypertenive encephalopathy

Neuromuscular diseases

Neuropathy ,UMNL ,LMNL (upper and lower

motor )

CNS

Nerve injury

Nerve compression

Wrong dose or concentration or additives

Adjuvant effect

Hypersensitivity to LA OR preservatives

Delayed recovery from regional

1. Immediate recovery from anaesthesia is a

concept of care during not just a place to put

the patient after surgery. Responsibility can

never be fully delegated by the anaesthetist

to others.

Summary

2. Most problems relate to Airway, Breathing

and/or Circulation; with delayed return of

consciousness and inadequate analgesia

being other common related issues. All these

should be anticipated.

3. Facilities required are the same as those

necessary for anaesthesia where-ever that might

be administered. If such facilities cannot be

duplicated in a separate location, then the safest

place to recover patients is in the operating room.

4. The most important monitor is a well

informed and skilled person; with immediate

access to anaesthetic assistance. Technical

support is important but sophisticated

electronic monitors are not universally essential

5. Discharge to a general ward should only

be considered when you have a conscious,

co-operative and comfortable patient who is

well oxygenated and well perfused; and

likely to remain so.

THANK YOU