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
10.
11.
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
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
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!!!!!!