Here Prof. Mridul M. panditrao, tries to explain, the concept of Post Anaesthesia care PAC and PACU, with graphics etc.

1. Dr. Mridul M. Panditrao
Consultant
Public hospital Authority’s
Rand Memorial Hospital
Freeport, Grand Bahama
Commonwealth of Bahamas

2. The Post- Anaesthesia Care
(PAC)

3. Introduction
 Recovery from anesthesia can range from
completely uncomplicated to life-threatening.
 Must be managed by skilled medical and
nursing personnel.
 Anesthesiologist plays a key role in optimizing
safe recovery from anesthesia
 Must be carried out in a well planned, protocol
based fashion

4. PAC
Definition
It is the specialized care given to the patients
who have undergone anaesthetic
management, by a team of well trained
professionals, in a specially
designed, equipped and designated area of
the hospital

5. PAC Vs. Post operative care
PAC is provided to
 anyone who has undergone anaesthesia
 anaesthesia might not be for a surgical
procedure
 patients undergoing ECT, Narco analysis
 patients under going Endoscopies
+
 all the patients who have undergone
surgeries

6. PACU
Definition : It is the
 Specially designated
 Specially designed
 Specially located
 Specially staffed
 Specially equipped
Area of hospital, for a
 Specific purpose !

7. 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.
 But one can trace it to “Lady of the lamp”: F. N.
 1920’s and 30’s: several PACU’s opened in the US and
abroad.
 It was not until after WW II that the number of PACU’s
increased significantly. This was due 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.

8. PACU Location
 Should be located close to the Operating Theater
 Immediate access to x-ray, blood bank, blood gas and clinical
labs.
 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, because the exposure to waste
anesthetic gases may be hazardous.
 National Institute of Occupational Safety (NIOSH) has
established recommended exposure limits of 25 ppm for
nitrous and 2 ppm for volatile anesthetics.

9. Design of PACU
 Size:
 Ideal 1.5 PACU bed for every Operating Room
 120 square foot per patient
 Minimum of 7 feet between beds
 Facilities:
 Fowler’s cot with side rails
 Piped Oxygen, Vacuum and Air
 Multiple electrical outlets
 Large doors
 Good lighting
 Isolation for Immuno-compromised patients

12. 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 the
anesthetic remains responsible for managing
the patient in the PACU.
 Adequate no. of ancillary staff, such as
technicians, ward boys and ayahs.

13. PACU Equipment
 Multi-parametric monitors (Automated BP,
pulse ox, ECG) 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.

14. Routine Post-Anaesthesia Care
 Criteria for shifting from OR---to---PACU
 Conscious, awake, responds to simple
commands
 Haemo dynamic stability
 Clinical evaluation and complete recovery
from NM blockade
 Maintenance of Oxygen Saturation
 Normothermia

15. PACU Standards
 1. All patients who have received general
anesthesia, regional anesthesia, or monitored
anesthesia care should receive postanesthesia
management.
 2. The patient should be transported to the PACU by
a member of the anesthesia care team that is
knowledgeable about the patient’s condition.
 3. Upon arrival in the PACU, the patient should be re-
evaluated and a verbal report should be provided to
the nurse.
 4. The patient shall be evaluated continually in the
PACU.
 5. Anaesthsiogist, concerned is responsible for
discharge of the patient.

16. Admission Report
 Preoperative history
 Intra-operative factors:
 Procedure
 Type of anesthesia
 Estimated Blood Loss (EBL)
 Urine output
 Assessment and report of current status
 Post-operative instructions

17. Postoperative Pain Management
 Intravenous opioids
 Diclofenac, I.V. Paracetamol and anti-
inflammatory drugs
 Midazolam for anxiety
 Epidural : LAAs and their adjuvants
 Regional analgesic blocks
 PCA and PCEA

18. Discharge criteria from PACU
 Neither an arbitrary time limit nor a discharge
score can be used to define a medically
appropriate length stay in the PACU accurately
 All patients must be evaluated by
anesthesiologist prior to discharge from PACU
 Criteria for discharge developed by the
Anesthesia department
 Criteria depends on where the patient is sent –
ward, ICU, home

19. Discharge criteria from PACU
 Easy arousability
 Full orientation
 Ability to maintain & protect airway
 Stable vital signs for at least 15 – 30
minutes
 The ability to call for help if necessary
 No obvious surgical complication (active
bleeding)

20. Discharge From the PACU
 Standard Aldrete Score:
 Simple sum of numerical values assigned to
activity, respiration, circulation, consciousness,
and oxygen saturation.
 A score of 9 out of 10 shows readiness for
discharge.
 Post-anesthesia Discharge Scoring System:
 Modification of the Aldrete score which also
includes an assessment of pain, N/V, and surgical
bleeding, in addition to vital signs and activity.
 Also, a score of 9 or 10 shows readiness for
discharge.

21. Standard Aldrete Score
Activity Respiration Circulation Consciousness Oxygen
Saturation
2: Moves all 2:Breaths deeply 2: BP + 20 mm 2:Fully awake 2: Spo2 > 92%
extremities and coughs of on room air
voluntarily/ on preanesthetic
command freely. level
1: Moves 2 1: Dyspneic, 1: BP + 20-50 1: Arousable on 1:Supplemental
extremities shallow or limited mm of calling O2 required to
breathing preanesthetic maintain Spo2
level >90%
0: Unable to 0: BP + 50 mm 0: Not responding 0: Spo2 <92% with
0: Apneic
O2
move of preanestheic
supplementation
extremities level

22. Post-anesthesia Discharge Scoring
System (PADSS)
Vital Signs Activity Nausea and Pain Surgical
(BP and Vomiting Bleeding
Pulse)
2: Within 20% of 2: Steady gait, 2: Minimal: treat 2: Acceptable 2: Minimal: no
preoperative no dizziness with PO meds control per the dressing
baseline patient; changes
controlled with required
PO meds
1: 20-40% of 1: Requires 1: Moderate: 1: Not 1: Moderate: up
preoperative assistance treat with IM acceptable to the to 2 dressing
baseline medications patient; not changes
controlled with
PO medications
0: >40% of 0: Unable to 0: Continues: 0: Severe: more
preoperative ambulate repeated than 3 dressing
baseline treatment changes

23. Safe guidelines for discharging to
home after ambulatory surgery
 Patient should be able to stand & take a few
steps ( sit on bed if C/ I for standing)
 Should be able to sip fluids
 Should be able to urinate
 Should be able to repeat post-operative
management
 Should be able to identify the escort
(cognitive function)

24. Post Operative Complications
 Nausea and Vomiting
 Respiratory Complications
 Failure to Regain Consciousness
 Circulatory Complications
 Fever

25. Nausea and Vomiting
 Most common complication in the PACU.
 DDX:
 Hypoxia
 Hypotension
 Pain
 Anxiety
 Infection
 Chemotherapy
 Gastrointestinal obstruction
 Narcotics/ volatile anesthetics/ etomidate
 Movement
 Vagal response
 Pregnancy
 Increased ICP
 Do:
 IV fluids
 Medications (Ondansetron/ metoclopramide/ Promethazine)
 position

26. Respiratory Complications
 Nearly two thirds of major anesthesia-related
incidents may be respiratory
 Do:
 Go to see the patient!
 Assess the patients vital signs and respiratory
rate.
 Evaluate the airway. R/o obstruction or foreign
body.
 Mask ventilate with ambu if necessary.
 Intubate and secure the airway.
 Look for causes of hypoxia.
 Send ABG, CBC, BMP. Get CXR.

27. Respiratory Complications
 Airway obstruction
 Hypoxemia
 Low inspired concentration of oxygen
 Hypoventilation
 Areas of low ventilation-to-perfusion ratios
 Increased intrapulmonary right-to-left shunt
 Increased Left to Right shunt

28. Respiratory Complications
 Airway Obstruction:
 Sagging tongue: Treated with triple maneuver
 Laryngeal Spasm:
 Due to secretions
 Due to irritable airways (smokers)
 Rx: 100% Oxygen through face mask
 Hydrocoritsone 100 mg IV
 If no improvement rapid intubation to secure the
airway

29. Respiratory Complications
 Hypoxemia:
 Low FIO2:
 Diffusion hypoxemia (N2O 31 times more soluble
than O2)
 Hypoventilation:
 Inadequate N.M. blockade recovery
 Respiratory depressant effect of volatile agents,
narcotics, benzodiazepines
 Hypocapnia intra operatively
 Upper abdominal incisions

30. Respiratory Complications
 Increased Right to Left Shunt:
 Atelectasis:
Inadvertent endobroncial intubation
Ateclectasis of the lung
Increased Shunt ( R to L )
Blockage of Brochus by blood or mucous plug
Pnemothorax:
following rib injury
following CVP placement

31. Failure to Regain Consciousness
 Preoperative intoxication
 Residual anesthetics: IV or inhaled
 Profound neuromuscular block
 Profound hypothermia
 Electrolyte abnormalities
 Thromboembolic cerebrovascular accident
 Seizure

32. Circulatory Complications:
 Hypotension:
 Decreased preload
 Decreased myocardial contractility
 Increased after load

33. Circulatory Complications:
 Decreased preload:
 Increased blood loss
 Increased III space loss
 Un diagnosed urinary loss
 Septicemia
 Decreased myocardial contractility:
 Depressant effect of GA drugs
 Pre-existing ventricular dysfunction
 Per operative Myocardial infarction
 Decreased After load:
 Volatile agents depression
 Septic shock
 Profound decreased SVR
 Septic shock
 Volatile agents effects

34. Circulatory Complications:
 Hypertension:
 Pain
 Hypercapnia
 Hypothermia
 Hypoxemia
 Excess Intra vascular volume
 Pre-existing hypertension

35. Circulatory Complications:
 Arrythmias:
 Electrolyte imbalance ( K )
 Hypoxia
 Hypercarbia
 Metabolic acidosis

36. Circulatory Complications:
 Myocardial Ischemia
 Increased risk:
 History of CAD
 CHF
 Smoker
 HTN
 Tachycardia
 Severe hypoxemia
 Anemia
 Same risk if the patient has GA or regional anesthesia.
 Treatment
 Oxygen, Streptokinase, NTG and morphine if needed
 12 lead EKG
 History
 Consult cardiology

37. Fever
 Causes:
 Infections
 Drug / blood reactions
 Tissue damage
 Neoplastic disorders
 Metabolic disorders
 Thyroid storm
 Adrenal crisis
 Pheochromocytoma
 MH
 Neuroleptic malignant syndrome
 Acute porphyria

38. Summary & Conclusion
 Anaesthesia is becoming very sophisticated!
 PAC is an absolutely essential care given by
a team of professionals!!
 Anaesthesiologists and Trained nursing staff
are the most important members of PACU!!!
 Thorough understanding of pathophysiology
of this period is very essential!!!!
 With well organized PACU, one can prevent
lot of post-operative morbidity & mortality!!!!!!