NURSING CARE OF POST-ANESTHESIA PATIENTS (Outlined)
Prof. Queenie Roxas-Ridulme, M.A.
LEARNING OBJECTIVES
 List the five standards of post anesthesia care.
 Recall the three scoring systems commonly used in the
PACU.
 Name complications associated with nausea and vomiting
and discuss anti-emetic medications.
 Describe common respiratory and cardiovascular
complications.
 Identify fluid and electrolyte complications.
 Discuss acute pain complications and pain relief.
 Recognize common temperature regulation and endocrine
complications.
 Review common maternal complications.
 Explain management of complications related to
medications.
HISTORY
 Before the advent of effective anesthesia people rarely
requested elective surgery.
 This is reflected in the 1821 to 1846 annual reports of the
Massachusetts General Hospital, which recorded only
about one such case each month. In fact, surgery of any
type was much less common before anesthesia, and it
was usually regarded as a last and desperate resort.
 The 1897 reminiscence of one elderly Boston physician
about the days before anesthesia portrays the intensity of
invasive procedures by recalling "yells and screams, most
horrible in my memory now, after an interval of so many
years" (Southern Nevada Professional Legal Nurse
Consultants, 2005).
 Oliver Wendell Holmes, Sr., is credited with introducing
the term anesthesia into the English language in 1846, a
mere four weeks after the first demonstration of ether.
 In October of that year, at Massachusetts General
Hospital in Boston, William T. G. Morton demonstrated the
use of ether as a means of rendering a patient
unconscious and free from surgical pain.
 Holmes was naming the state we now call general
anesthesia (the "ae" letter combination having become
obsolete). This state is clinically defined by degrees of
effect in four criteria:
 Amnesia (loss of recall for the event)
 Analgesia (insensibility to pain)
 Hypnosis (unconsciousness)
 Muscle relaxation
TYPES OF ANESTHESIA
 General Anesthesia
 Regional Anesthesia
 Monitored Anesthesia - when small amounts of an
anesthetic medication are given to sedate or relax the
person for a minor procedure or during regional
anesthesia
 Local Anesthesia
 Prior to the establishment of specialized areas, the
standard of care in most hospitals was a direct return of
postsurgical patients to large open wards, where the best
they could be offered was a bed close to the nurse's
station, by the doorway.
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 In the classic 1942 textbook Clinical Anesthesia, physician
John Lundy advised students that patients should be
returned to their rooms with mouth airways in place, and
that
the floor nurse should "return the airway to the operating
room for use by other surgical candidates after the patient
recovered" (Lundy, 1942).
CURRENT PRACTICE
 Current standards of care for the patient in post
anesthesia (PAC) calls for anesthesiologists, nurses, and
surgeons to work together as a team.
 Together they observe for the presence of medical,
surgical, or anesthesia-related problems, with the goal of
providing immediate attention and rapid treatment, thereby
minimizing the effects of complications.
 Planning for post anesthesia care should begin during the
preoperative period, when anesthetic and pain
management techniques are discussed with the patient
and family.
 Postoperative care involves several phases, including
transferring the patient directly to traditional or phase I
recovery (PAC), to accelerated or phase II recovery, or
directly to intensive-care units (ICUs) according to the
area of specialty (eg, neurosurgical, cardiothoracic,
pediatric, neonatal).
 Dramatic increases in the number of outpatient/ambulatory
procedures, combined with drastically shortened
postoperative stays, have created challenging trends in
post anesthesia recovery.
 Pressing needs for timely discharge to home after a brief
stay in a "same day" unit actually increases the need for
vigilance by staff so that imminent complications may be
recognized and treated before the patient leaves the care
of experienced staff.
 Ambulatory, accelerated, phase II, or outpatient recovery
units are all names of care units that focus on specific
groups in need of post anesthesia services.
ASA STANDARDS FOR POST-
ANESTHESIA CARE
(Approved by House of Delegates on October 12, 1988
and last amended on October 27, 2004)
 These standards apply to postanesthesia care in all
locations. These standards may be exceeded based on
the judgment of the responsible anesthesiologist.
 They are intended to encourage quality patient care, but
cannot guarantee any specific patient outcome.
 They are subject to revision from time to time as
warranted by the evolution of technology and practice.
 Under extenuating circumstances, the responsible
anesthesiologist may waive the requirements marked with
an asterisk (*); it is recommended that when this is done,
it should be so stated (including the reasons) in a note in
the patient’s medical record.
STANDARD I
ALL PATIENTS WHO HAVE RECEIVED GENERAL
ANESTHESIA, REGIONAL ANESTHESIA OR MONITORED
ANESTHESIA CARE SHALL RECEIVE APPROPRIATE and providing cardiopulmonary resuscitation for patients in
POSTANESTHESIA MANAGEMENT. the PACU.
 A Postanesthesia Care Unit (PACU) or an area which
provides equivalent postanesthesia care (for example, a STANDARD V
Surgical Intensive Care Unit) shall be available to receive A PHYSICIAN IS RESPONSIBLE FOR THE DISCHARGE OF
patients after anesthesia care. All patients who receive THE PATIENT FROM
anesthesia care shall be admitted to the PACU or its THE POSTANESTHESIA CARE UNIT.
equivalent except by specific order of the anesthesiologist  When discharge criteria are used, they must be approved
responsible for the patient’s care. by the Department of Anesthesiology and the medical
 2. The medical aspects of care in the PACU (or equivalent staff. They may vary depending upon whether the patient
area) shall be governed by policies and procedures that is discharged to a hospital room, to the Intensive Care
have been reviewed and approved by the Department of Unit, to a short stay unit or home.
Anesthesiology.  In the absence of the physician responsible for the
 3. The design, equipment and staffing of the PACU shall discharge, the PACU nurse shall determine that the
meet requirements of the facility’s accrediting and patient meets the discharge criteria. The name of the
licensing bodies. physician accepting responsibility for discharge shall be
noted on the record.
STANDARD II
 A PATIENT TRANSPORTED TO THE PACU SHALL BE  Refer to Standards of Post Anesthesia Nursing Practice
ACCOMPANIED BY A MEMBER OF THE ANESTHESIA 1992 published by ASPAN, for issues of nursing care.
CARE TEAM WHO IS KNOWLEDGEABLE ABOUT THE
PATIENT’S CONDITION. SCORING SYSTEMS
 THE PATIENT SHALL BE CONTINUALLY EVALUATED  Systemized methods of patient scoring help to provide an
AND TREATED DURING TRANSPORT WITH objective measurement for care.
MONITORING AND SUPPORT APPROPRIATE TO THE  Scoring systems aid in determining when an ambulatory
PATIENT’S CONDITION. surgery patient is ready to go home, or that an extended
stay for observation is warranted.
STANDARD III
UPON ARRIVAL IN THE PACU, THE PATIENT SHALL BE 1. SIMPLIFIED SCORING SYSTEM
RE-EVALUATED AND A VERBAL REPORT PROVIDED TO
 The Simplified Scoring System is a straightforward system
THE RESPONSIBLE PACU NURSE BY THE MEMBER OF
that lives up to its name by being relatively easy to use.
THE ANESTHESIA CARE TEAM WHO ACCOMPANIES THE
 Its scoring is on a scale of 0 through 6, with 6 representing
PATIENT.
complete recovery (Table 1).
 The patient’s status on arrival in the PACU shall be
 It is used as a quick method to assess objectively the
documented.
progression from surgical anesthesia to recovery.
 Information concerning the preoperative condition and the
 The time intervals set for recording scores are
surgical/anesthetic course shall be transmitted to the
recommended for admission to PACU at 5-, 15-, and 30-
PACU nurse.
minute intervals, and upon discharge (Recovery, 2005.)
 The member of the Anesthesia Care Team shall remain in
the PACU until the PACU nurse accepts responsibility for
TABLE 1 SIMPLIFIED SCORING SYSTEM FOR
the nursing care of the patient.
POSTOPERATIVE RECOVERY
STANDARD IV PARAMETER FINDING POINTS
THE PATIENT’S CONDITION SHALL BE EVALUATED Consciousnes Awake 2
CONTINUALLY IN THE PACU. s
 The patient shall be observed and monitored by methods Arouses and responds to 1
appropriate to the patient’s medical condition. Particular stimulus
attention should be given to monitoring oxygenation, Not responding to stimuli 0
ventilation, circulation, level of consciousness and Airway Coughs on command or is 2
temperature. During recovery from all anesthetics, a crying
quantitative method of assessing oxygenation such as
Maintains a good airway and 1
pulse oximetry shall be employed in the initial phase of is breathing easily
recovery.* This is not intended for application during the
Airway requires maintenance 0
recovery of the obstetrical patient in whom regional
Movement Moves limbs purposefully 2
anesthesia was used for labor and vaginal delivery.
Nonpurposeful movements 1
 An accurate written report of the PACU period shall be
Not moving 0
maintained. Use of an appropriate PACU scoring system
is encouraged for each patient on admission, at
appropriate intervals prior to discharge and at the time of SIMPLIFIED SCORING SYSTEM INTERPRETATION
discharge.  Minimum score 0
 General medical supervision and coordination of patient  Maximum score 6
care in the PACU should be the responsibility of an  0 indicates still fully anesthetized
anesthesiologist.  6 indicates fully recovered
 There shall be a policy to assure the availability in the  Using the Simplified System, a total of 0 indicates still fully
facility of a physician capable of managing complications anesthetized and a total of 6 indicates that the patient is
fully recovered.
2
 Circulatory Blood pressure stable; pulse 0
2. MODIFIED ALDRETE SCORING SYSTEM always <100 (all blood pressure
 Another scoring system that lists objective, observable readings are systolic)
criteria is based on the Apgar score and was developed by Blood pressure change less than 1
J. Antonio Aldrete. 30%; pulse 100–120
Vasopressors or digitalis therapy 2
 It is extensively used because it can be applied
Blood pressure <100 despite 3
immediately and repeatedly as a convenient means to
treatment
evaluate progress in recovery from anesthesia.
Decompensated 4
 A patient score of 9 in the operating room or PACU
Severe shock 5
enables a satisfactory move to a lesser level of care
Respiratory Rate under 15; breath holding 0
(Barone, Pablo & Barone, 2004.)
more than 25 sec
MODIFIED ALDRETE SCORE (POSTANESTHESIA Rate 15–20; productive cough 1
RECOVERY SCORE) Rate over 20; rales or 2
temperature up to 100°F
 Consciousness Temperature over 100°F, partial 3
2 = Fully awake atelectasis
1 = Responds to name Major atelectasis 4
0 = No response Pneumonia 5
 Activity on command CNS Amnesic, satisfied 0
2 = Moves all extremities Confused or recalls induction 1
1 = Moves two extremities Dissatisfied with anesthesia for 2
0 = No movement any reason
 Respiration Extrapyramidal signs 3
2 = Free deep breathing Major neurologic complications 4
1 = Dyspneic, hyperventilating, obstructed breathing Coma 5
0 = Apneic GI Nothing 0
 Circulation No more than 3 episodes of 1
2 = Blood pressure within 20% nausea
 of pre-op level Nausea, vomited once only 2
1 = Blood pressure within Vomiting 3
 50%–20% of pre-op level Ileus 4
0 = Blood pressure 50%, or Evisceration or perforation 5
 less, of pre-op level Renal Voids over 800 mL 0
 Oxygen saturation (24-hr volumes)
2 = SpO2 >92% on room air Over 800 mL per catheter 1
1 = Supplemental O2 required Voids 500–800 mL 2
 to maintain SpO2 >92% 500–800 mL per catheter 3
0 = SpO 2 <92% with O2 Under 500 mL 4
 supplementation Anuria 5
 Total Score
10 = Score = 9 needed to leave PACU NOTRE DAME POST ANESTHETIC SCORING SYSTEM
 The post anesthesia score for each organ system is
3. NOTRE DAME POST-ANESTHETIC SCORING designed to be evaluated separately: the lower the score
SYSTEM in each organ system, the better.
 The Post Anesthetic Scoring System of Notre Dame  Drawbacks to this system are its inherent complexity and
Hospital combines aspects of the Modified Aldrete System —most important—that unless great care is taken to use
with an additional scoring system for the evaluation of the data achieved, reassessments several days after
postoperative pain, emesis, and other factors indicative of surgery have little meaning in all but the most serious
post anesthesia complications (Table 2). cases (Recovery, 2005).
 Patients are scored in each area at the time of admission
and at regular intervals during their stay in the PACU. PREOPERATIVE EVALUATION
 This system has the additional benefit of allowing patients  The American Society of Anesthesiologists (ASA) has
to be scored on the second, fifth, and fifteenth days developed a classification system that is used to identify
following surgery and their progress mapped. patients preoperatively by degree of risk for complications.
 This ability to follow a patient's progression over a longer  Individuals identified as ASA III and above, neonates,
course is a mixed blessing, as the drive to shorter premature infants, emergency surgical procedures,
procedure stays and observation periods makes a portion abdominal procedures, and operations that require
of this system unusable except in extreme instances. general anesthesia lasting for several hours are all
candidates for extended observation in a skilled post
TABLE 2. NOTRE DAME POST ANESTHETIC SCORING anesthesia care setting.
SYSTEM
Organ System Finding Points American Society of Anesthesiologists Physical Status
Classification System

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ASA I
 Patient's health: excellent, with no systemic disease
 Limitations on activity: none
 Danger of death: none
 Excluded: persons at extremes of age (very young, very
old)
American Society of Anesthesiologists Physical Status
Classification System
ASA II
 Patient's health: disease of one body system
 Status of underlying disease: well controlled
 Limitations on activity: none
 Danger of death: none
American Society of Anesthesiologists Physical Status
Classification System
ASA III
 Patient's health: disease of more than one body system or
one major system
 Status of underlying disease: controlled
 Limitations on activity: present but not incapacitated
 Danger of death: no immediate danger
American Society of Anesthesiologists Physical Status
Classification System
ASA IV
 Patient's health: poor, with at least one severe disease
 Status of underlying disease: poorly controlled or end-
stage
 Limitations on activity: incapacitated
 Danger of death: possible
American Society of Anesthesiologists Physical Status
Classification System
ASA V
 Patient's health: very poor, moribund
 Limitations on activity: incapacitated
 Danger of death: imminent
ADMISSION TO THE PACU
 Three actions are essential to decreasing the
postoperative complication rate. These are:
 Management of the patient's airway with provision of
oxygen
 The measurement and recording of vital signs by the
nurse with communication of this data to the
anesthesiologist
 A report by the anesthesiologist to the PAC nurse
assuming care
 This report should include, but not necessarily be
limited to, the following:
 Patient identification (name, age, sex, language or
comprehension limits such as hard of hearing/blindness)
 Diagnosis, brief medical history, surgical procedure,
surgeon
 Review of preanesthetic assessment including allergies,
medical history, and daily medications
 Anesthetic course, technique, agents used, complications,
and anticipated need for pain medications
 Intraoperative fluid balance and laboratory data
 Anticipated problems
 Postanesthetic orders (eg, oxygen administration, fluid
administration, anti-emetic and analgesic treatment)
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 On accepting the patient, the nurse is expected to
evaluate and document the patient's status both at the
time of admission and at regular intervals until the time of
discharge from the unit.
 Commonly a scoring system such as one of those
previously discussed is used.
 Systems such as the Modified Aldrete tend to be most
widely used, yet, due to limitations with cardiac
dysrhythmias, oliguria, or severe nausea and vomiting,
even the Modified Aldrete should never take the place of
sound judgment.
 Routine postoperative monitoring includes pulse oximetry,
respiration pattern and rate, cardiac rate and rhythm, level
of consciousness, blood pressure and temperature.
 Timing of vital-sign monitoring depends on the condition of
the patient but is commonly set at once every 15 minutes
for the first hour then each half-hour thereafter.
POST ANESTHETIC COMPLICATIONS
 To identify and evaluate the frequency of complications
occurring in a post anesthesia care setting, in 1992 the
Yale University School of Medicine reported on a massive
study of 18,473 consecutive patients entering a PACU at
one university teaching hospital. They used a
standardized collection form to determine the incidence of
intraoperative and PACU complications. Results of this
classic study showed that the overall complication rate
among patients was 26.7% (Hines, 1992).
 In the Yale study, the post anesthesia component of the
combined complication rate was 23.7% and the
intraoperative complication was rate 5.1% (a small
percentage of patients fell firmly into both categories). Of
the complications recorded by this study, nausea and
vomiting had the highest frequency, respiratory problems,
especially the need for upper-airway support, was second,
and hypotension serious enough to require treatment was
the third most common complication.
 A study similar to the original Yale classic was published
in June 2005. This larger study, composed of all
postoperative patients passing through the PACU at the
Vancouver General Hospital, looked at postoperative
complications (POC) from April 2001 through March 2004.
Interestingly, the authors concluded that "Despite
pharmacological and medical aptitude advances in the
past ten years, our incidences of POC, such as
postoperative nausea and vomiting, hypotension, and
dysrhythmias, remain similar to estimates from [the Yale
study] in 1992" (Mayson, Beestra & Choi, 2005.)
 Complications from the 37,071 patients in the Vancouver
General study broke down into the following general
groupings: respiratory complications (15.2%);
cardiovascular complications (12.3%); postoperative
nausea and vomiting (PONV, 9.4%); and excessive pain
(7.2%).
 A more specific breakdown of respiratory complications
showed: the complication of inability to extubate in a timely
manner after surgery (5.8%), oxygen desaturation (2.1%),
and hypoventilation (2%).
 Among the most common cardiovascular complications
were hypotension (4.5%), hypertension (4.3%), and
dysrhythmias (2.8%).
 The incidence of PONV was highest after gynecologic
procedures (15.5%), followed by spine surgery (12.96%),
 reconstructive orthopedics (11.9%), and general surgical
procedures (10.9%).
 Incidence of excessive pain was highest after spine
surgery (12.3%), thoracic procedures (10.36%),
gynecologic procedures (9.6%), and general surgical
procedures (8.9%).
 Physicians and support staff in the PACU must take the
time to become familiar with postoperative problems and
their management.
 The most common complications found in the post
anesthesia setting can be categorized as nausea/vomiting,
respiratory, cardiovascular, fluid/electrolyte, acute pain,
temperature regulation, endocrine, and medications.
1. NAUSEA AND VOMITING (PONV)
 It is frequent enough and of sufficient seriousness that it is
considered by many to be the most common reason for
delay in discharge as well as for unanticipated admission
overnight after ambulatory surgery.
 When severe enough, PONV may result in lengthened
recovery time and even require admission to the hospital,
both of which may trigger further complications and
increase financial burdens
 Nausea is the uncomfortable sensation of an impending
episode of vomiting. It is often associated with prodromal
symptoms such as increased salivation, frequent
swallowing, pallor, and tachycardia. Vomiting is a
complicated process, mediated by a central "vomiting
center" that resides in the brainstem in the region of the
tractus solitarius. The vomiting center (also called the
parvicellular reticular formation, or emetic center) receives
inputs from the pharynx, gastrointestinal tract,
mediastinum, cranial nerves, the higher cortical centers
(eg, the visual, gustatory, olfactory, and vestibular
centers), and the chemoreceptor trigger zone (CTZ).
 The vomiting center receives varied input and initiates the
vomiting sequence by sending chemical messages that
initiate the act of vomiting.
 Because the vomiting center receives input from different
types of receptors, there is no single drug that can block
all of the pathways and thus serve as a universally
effective anti-emetic agent. Antagonism of any of the
receptors contributes to the alleviation of nausea.
 Risk factors associated with increased incidence of PONV
include long duration of anesthesia, the use of inhalation
anesthetics, intraoperative use of opioids, the use of
reversal agents, and even the undergoing of specific
elective procedures that include gynecologic,
laparoscopic, middle-ear, orchiopexy, termination-of-
pregnancy, and strabismus surgery.
 Other pre-existing factors that increase the chances of
PONV are being of female gender, pre menstrual period,
diabetes, pregnancy and, interestingly enough, being a
nonsmoker. Postoperative risk factors that have been
identified include the presence of pain, hypotension,
hypoxemia, hypoglycemia, gastric bleeding, increased
intracranial pressure, inadequate hydration, use of
narcotics, the presence of anxiety, and too early oral
intake (Candiotti et al., 2005.)
 Patients with a history of PONV or those at high risk
should be treated both prophylactically and
intraoperatively. Adequate hydration is essential, and
narcotics should be used sparingly. Regional pain-block
5
techniques have been found to be helpful for
postoperative pain relief, allowing opiates to be minimized.
 Analgesic adjuncts such as the NSAID ketorolac (Toradol)
are also useful. However, nitrous oxide, etomidate,
ketamine, and neostigmine should be avoided if possible
because they are associated with an increased incidence
of postoperative nausea. Hypotension, pain, and anxiety
must be aggressively controlled.
 In high-risk PONV patients, anti-emetic medications
should be given early and the patients kept recumbent as
much as their condition allows. Oral fluids should be
withheld for several hours postoperatively. Other classes
of drugs, such as butyrophenones, phenothiazines, or
dopaminergic agents may be required in severe cases of
PONV.
 Aggressive and early treatment of the conditions
contributing to nausea in the PACU often averts an
extended admission. Patient education includes
acknowledging that, although steps can and will be taken
to minimize postoperative nausea and vomiting, it is not
possible to guarantee the absence of this disturbing
complication.
ANTI-EMETIC MEDICATIONS
 Butyrophenones - Droperidol (Inapsine)
 Benzamides - Metoclopramide (Reglan)
 Anticholinergics - Scopolamine ("transderm scop")
 Phenothiazines
 Serotonin Antagonists
2. RESPIRATORY COMPLICATIONS
 The most common of these problems often correlate
directly to specific causative effects. Hypoventilation, for
example, is commonly a direct result of the effects of the
anesthetic agent and technique chosen.
 Hyperventilation tends to be a result of pain, or, less
often, of increased intracranial pressure and pathology.
 Bronchospasm can be a result of pre-existing disease
conditions or the presence of triggering secretions.
 Pulmonary edema is associated with fluid overload or
cardiac shock.
 The complication of pulmonary embolism is generally
directly associated with venous thrombosis, or, less
frequently, fat emboli.
 The complication of aspiration (the inhalation of any
foreign material into the lungs) may occur more frequently
than was once thought.
 Although predisposing factors may be highly
individualized, the traditional view holds that aspiration
correlates closely with the presence of vomiting and high
gastric content volumes.
 Should aspiration occur and symptoms develop,
supportive techniques may include endotracheal
intubation, lung washing to remove and dilute materials,
and mechanical support ventilation.
 The use of steroids, with or without antibiotic therapy, has
not been found to improve outcomes in the absence of
infection.
 If aspiration has been suspected in the ambulatory
patient, yet the patient remains asymptomatic for two
hours (without hypoxemia on room air, and with a normal
chest radiograph), it is thought that the patient may safely
be discharged (Asai, 2004).
 Observable factors that increase the likelihood for
postoperative ventilatory support include pre-existing lung
disease, obesity, advanced age, a smoking history, low
preoperative arterial oxygenation, thoracic and upper
abdominal surgery, recent large narcotic administration,
and a large intraoperative blood loss with excessive
crystalloid replacement.
 Hypoxemia (the condition of having a below-normal
oxygen content in arterial blood) can be detected easily
and rapidly in the post anesthesia setting by the routine
use of pulse oximetry
 The primary mechanism of postoperative hypoxemia that
results in the need for induced ventilation is a decreased
functional capacity.
 This can be caused by pain, abdominal distention,
impaired diaphragmatic function, and inability to tolerate
the supine position
 Early recognition of this condition can facilitate therapeutic
intervention before a life-threatening situation develops.
 Some features of hypoxia (another term for hypoxemia)
may overlap with those of hypercapnia (excess of carbon
dioxide in the blood).
 The early clinical signs of hypoxemia are tachycardia,
tachypnea, agitation, and altered mental status, whereas
hypotension, bradycardia, obtundation, and cardiac arrest
are late signs.
 Reactive airway disease (asthma) deserves its own
mention because it is a potent cause of bronchospasm
postoperatively.
 The term asthma is being replaced with what many
consider a more accurate term—reactive airway disease
(RAD).
 Those with RAD (5% and growing in the United States)
have bronchial passages that are more sensitive to
irritation than normal.
 This hypersensitivity leads to inflammation in the tiny
airways deep in the lungs. The inflammation in turn
causes excess mucus production and tightening of airway
muscles that wind around the bronchial tubes like laces.
 Swelling, mucus, and muscle tightening interact to cause
narrowing of the airways.
 Wheezing (whistling and labored breathing) usually
results, but a dry cough is sometimes the only sign.
 Tightening of the airway passages in the immediate post
anesthesia environment can be handled with placement of
a laryngeal mask airway combined with positive-pressure
ventilation.
 This intervention can maintain adequate oxygenation while
avoiding the additional physical insult of a second
intubation.
 Patients with obstructive sleep apnea syndrome
(OSAS), or snorers, are at increased risk of reduced
oxygen saturation in arterial blood. Sedatives, anesthetics,
and lying in the supine position can impair upper-airway
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muscle activity, jeopardize airway patency, and decrease
functional residual capacity, predisposing these patients to
desaturation.
 The use of the combined approach of a sitting position and
nasal continuous positive airway pressure (NCPAP),
started before surgery and continued postoperatively, has
been found to be helpful in handling patients with OSAS.
 Bronchospasm (the spasmodic contraction of smooth
muscles of the bronchi) is usually associated with asthma,
chronic obstructive pulmonary disease (COPD), or
smoking.
 Another uncommon cause of bronchospasm is an allergic
reaction to drugs, blood products, or latex.
 Treatment for life-threatening spasm in the post
anesthesia care unit often includes a nebulized selective
beta-2 agonist (terbutaline or albuterol), the use of
intravenous theophylline (5–6 mg/kg infused as 0.2
mg/kg/hr), along with the concurrent use of inhaled
bronchodilators.
 Pulmonary embolism, the sudden lodging of a blood clot
(or, less commonly, fat or amniotic fluids) in a pulmonary
artery with subsequent obstruction of the blood supply, is
a very unusual occurrence.
 Most often a diagnosis is made by exclusion, eliminating
other causes first. It should be suspected, however, in the
presence of unexpected cardiorespiratory collapse.
 Precipitating factors include obesity, hypercoagulability,
oral contraceptive use, varicose veins, old age, prolonged
immobility, fractures of pelvis, hip, or leg, as well as the
presence of malignancy.
 Symptoms include shock, dyspnea with tachypnea,
hyperventilation, and hypoxemia.
 Preventive measures in high-risk patients include the use
of elastic stockings, intermittent pneumatic leggings, and
low-dose heparin to inhibit clot formation.
 Treatment of pulmonary embolism is supportive, with the
expectation that the thrombi will lyse within a matter of
days to several weeks (Merck, 2005).
 Hoarseness and sore throat occur in about one-third of
intubated patients, although it does not usually cause
respiratory problems (unless the airway was already
compromised in some manner).
 Spontaneous resolution occurs within two weeks in almost
all who experience this complication.
 Prophylactic measures include an experienced intubator
and use of bland lubricant
 Medication combined with unconsciousness can lead to
potentially dangerous events that can compromise patient
respiration in the PACU. These events tend to occur by
three major mechanisms:
 Airway obstruction
 Respiratory insufficiency caused by certain medications
 Chemical pneumonia
 When a patient is unconscious, slackened nasal or
oropharyngeal tissues, muscle rigidity in the neck, or
upper-respiratory secretions can obstruct the airway. The
risk can be lessened by turning the patient on the side with
head flat or slightly lowered.
 Check breathing using your stethoscope. Listen for breath
sounds—don't rely on chest motion only.
 Observe and palpate the chest to make sure that both
sides expand equally; if they don't, one lung may be
obstructed.
 Check for straining of the accessory breathing muscles,
tachycardia, and hypoxia; these are signs that obstruction
is interfering with effective breathing. Cyanosis may occur
unless the obstruction is relieved.
 To relieve obstruction, extend the patient's neck and thrust
the jaw forward in a chin lift/jaw thrust maneuver, as when
initiating cardiopulmonary resuscitation. This clears the
tongue, nasal, and oropharyngeal tissues from the airway.
 If signs of obstruction persist, secretions may need to be
suctioned. Some patients may require the insertion of an
oral or nasal airway, or assisted ventilation by mask or
bag.
 Respiratory insufficiency may occur because inhalation
anesthetics and narcotics depress respiratory drive.
 Intraoperative muscle relaxants compound the problem by
weakening the respiratory muscles.
 The use of supplemental oxygen is a standard practice
following any anesthetic until the patient is fully awake.
 Remember that the patient's need for oxygen increases
with shivering, which is a common response to anesthesia
and the cooling effects of prolonged surgery.
 If during the immediate postoperative period the patient
falls asleep and begins to breathe shallowly, it may be due
to insufficient oxygen. Arouse the patient and encourage
slow, deep breathing. This will often be sufficient while
medication is exiting the system.
 To assess for respiratory insufficiency, listen for breath
sounds and check the rate, depth, and ease of breathing.
Anesthesiologists typically ask to be called if respirations
fall below 10 per minute or if oximetry measurements
show hemoglobin saturation below 90%.
 In the case of severe respiratory depression, the patient
may be given a narcotic reversal agent such as naloxone
(Narcan), or the patient may be placed on mechanical
ventilation until medications have been metabolized to the
extent that respiratory drive and effort will support effective
breathing.
 Narcotics and inhalation anesthetics suppress cough and
gag reflexes, leaving the still-unconscious patient at a high
risk for aspiration of gastric secretions and possible
secondary chemical pneumonia. One of the most common
preventive measures is to keep the unconscious patient in
a side-lying position with the head lowered to decrease the
risk of aspiration.
 In order to check for aspiration, auscultate all areas of the
lungs for wheezing and rales every 10 to 15 minutes and
notify the anesthetist if you hear suspicious lung sounds.
 Other observable symptoms include restlessness,
dyspnea, cyanosis, tachypnea, tachycardia, cough, and
eventually, fever.
 The sooner the patient receives treatment, (which may
include antibiotics, oxygen, bronchodilators, or steroids)
the better the chances of avoiding a life-threatening
hospital-acquired pneumonia.
7
 No matter what the complication, the use of a structured
assessment plan within the PACU is essential for early
recognition and treatment of respiratory complications.
 Utilize assessment scales for auscultation and pulse
oximetry.
 Constant and consistent observation of the post anesthetic
patient is an important habit to develop. This will ensure
prompt and appropriate intervention.
 Cardiovascular Complications
 Staff should be alert for the presence of four keys
cardiovascular events in the PACU. These include the
following:
 Hypertension
 Hypotension
 Tachycardia
 Bradycardia
 Identifying these key events allows clinicians to problem-
solve and isolate the causes underlying what is being
observed in the PACU (eg, myocardial infarction,
internalized hemorrhage, cerebrovascular infarction,
emboli).
3. HYPERTENSION
 Acute hypertension can be defined as a blood pressure
20% greater then the patient's preoperative baseline
pressures.
 In post anesthesia care, this increase can be induced by
pain, urinary retention, hypothermia, nausea, hypoxia,
hypercarbia, myocardial ischemia, or the impairment of
blood flow to any major system.
 Any abnormality in intracranial blood flow will especially
affect blood pressure.
 Postoperative hypertension is often found in conjunction
with arteriosclerotic disease.
 Arteriosclerosis is thought to promote an exaggerated
response to stimuli that may generate vasoconstriction.
 Some procedures, including abdominal aneurysm repair,
carotid endarterectomy, and intracranial surgery, have
been associated with a higher incidence of hypertension.
 Hypertension and cerebral hyperperfusion are often seen
in the immediate postoperative period after craniotomy
(Mandel, 2002).
 Treatment for acute hypertension mandates adequate and
early pain relief, bladder catheterization (if indicated), and
the use of fast-acting medications with the intent of
breaking the vasoconstrictive cycle.
 It is particularly important to break this cycle when there
are signs of end organ damage, such as severe
headache, persistent chest pain, or hematuria.
 Some of the widely used agents for acute treatment of
emergent hypertension include the following (Merck,
2005):
 Diazoxide
 Sodium nitroprusside
 Nitroglycerin
 Labetalol
 Nifedipine
4. HYPOTENSION
 The common usage of the term refers to an abnormally
low systemic blood pressure as compared to preprocedure
baseline pressures.
 Any factor that seriously lowers cardiac output or
peripheral vascular resistance (or both) can significantly
lower systolic blood pressure.
 There is a fine line between hypotension and shock.
 It is important to recognize that a patient may not be
hypotensive, yet could develop shock in a short period of
time.
 Clinical findings like oliguria, altered mental status,
peripheral cyanosis, or pallor and cool skin temperature
are red flags for impending hypotension/shock.
 Accompanying clinical findings that sometimes support the
diagnosis of shock include tachycardia, tachypnea, and
hypothermia (Mandel, 2002).
 New-onset hypotension in the PACU is almost always a
sign of an unwanted medication interaction, hypovolemia,
or blood loss.
 Other causes can include exposure of body cavities for
prolonged periods, the handling of bowel and mesentery,
as well as dissections in the retroperitoneal space (eg, in
abdominal aortic aneurysm dissections or
pancreaticoduodenectomy).
 The specific treatment of hypovolemic hypotension is to
restore adequate circulating intravascular volume. This
can be done with one or a combination of whole blood,
packed red blood cells, albumin or hetastarch, or a
balanced electrolyte solution such as lactated Ringer's
solution.
 Treatment of hypotension thought to be related to
medication effects includes the use of specific reversal
agents when indicated, deep breathing in order to "wash
out" inhalation agents, the use of supplemental oxygen,
and adequate fluid replacement.
 In the treatment of hypotension, the mainstays of
treatment are the achievement of homeostasis, fluid
resuscitation, and the use of blood products.
 The use of pressor agents (vasopressors) may be needed
in some settings, but these agents should not be
substitutes for adequate volume resuscitation.
 Vasopressors are agents that augment both coronary and
cerebral blood flow during the low-flow states associated
with shock. The following vasopressors are commonly
used to treat hypotension in the PACU:
 Dopamine (Intropin)
 Norepinephrine (Levophed)
 Epinephrine (Adrenalin)
 Vasopressin (Pitressin)
5. TACHYCARDIA
 Tachydysrhythmias in the PACU most often consist of
sinus tachycardia (heart rate greater than 100 bpm) or
supraventricular tachycardia (SVT).
 It is important to ascertain the hemodynamic response of
the patient to the dysrhythmia.
 In patients with SVT who are not hemodynamically stable,
synchronized cardioversion may be indicated.
 Unstable SVT shows manifestations of hypotension,
mental status change, and pulmonary edema or
myocardial ischemia.
 If the patient is hemodynamically stable, it is important to
determine if the dysrhythmia is a physiologic response to
8
physical or emotional stress and then correct the
underlying problem.
 Common causes for tachycardia seen in the PACU
include pain, hypovolemia, anemia, fever, hypoxia, and
hypercapnia.
 In the PACU, pain is probably the most common cause of
tachycardia.
 Pain may originate from the surgical incision site, but it
may also be present due to an over-distended bladder or
even a strain resulting from positioning during the
procedure.
 Treatment of the first includes appropriate analgesics and
positioning, while the latter necessitates voiding.
 During surgical procedures there is potential for massive
fluid shifts due to third spacing and evaporation.
 Third spacing is the movement of bodily fluids from their
usual location within vascular spaces into those areas
outside of the vascular system, while evaporation is the
process by which the body loses fluid into the atmosphere.
 Evaporation is greatly increased whenever the protective
confines of the skin are breached.
 The skin is the primary protection for the moist tissues that
form the inner portions of our bodies.
 It is not uncommon for patients to present to the PACU
with a relatively depleted intravascular fluid load.
 Compensatory physiologic tachycardia is a protective
mechanism to provide adequate tissue profusion.
 The appropriate treatment is volume replacement
 Anemia due to surgical blood loss may also produce a
compensatory physiologic tachycardia.
 The underlying cardiac status often determines the
approach to tachycardia due to anemia. Does the
tachycardia present an increased myocardial oxygen
demand in a patient with coronary artery disease that
cannot be met without inducing rate related ischemia? The
acuity of the anemia must also be addressed.
 In today's practice of transfusion medicine, it is important
to be as conservative as possible in administering blood
products because of the increased risk of infectious
disease transmission (Mandel, 2002).
 Fever is a physiologic response that may accompany a
wide variety of illnesses, and it provides a marker of
disease activity.
 In the surgical patient, it may represent as underlying
infection and is the response to endogenous or exogenous
pyrogens.
 It may also be caused by overzealous heating of
intravenous fluids and inspired gases, and/or overheating
of the operating room and heating blanket. The etiology of
fever should always be investigated.
 In the PACU, fever may produce tachycardia that, in the
patient with underlying coronary artery disease, can cause
ischemia.
 Treatment options include use of antipyretics, cooling
blankets, and ice packs in severe cases
 On a related note, shivering is a mechanism that the body
uses to produce heat. Often patients arrive shivering in the
PACU.
 Shivering can result in a significant increase in oxygen
consumption, which may be detrimental to the patient with
limited cardiac reserve.
 Treatment includes warming the patient and possibly
judicious use of meperidine (Demerol) for the express
purpose of decreasing shivering.
 Tachycardia is also a physiologic response to hypoxia and
may first become apparent when the patient arrives in the
PACU.
 In the immediate postoperative period, hypoxia may
represent the residual effects of anesthetic drugs or
response to the type of surgery.
 Hypoxia may be a reflection of alveolar dilution of oxygen
secondary to nitrous oxide elimination, the phenomenon of
so-called diffusion hypoxia.
 It may also represent alveolar hypoventilation due to the
continued respiratory depressant effects of the potent
volatile anesthetics or residual effects of muscle relaxants.
 The mechanical effect of upper-abdominal or thoracic
surgery on respiratory mechanics is known to decrease
ventilatory effort.
 Right-to-left intrapulmonary shunting of blood due to
atelectasis, ventilation-perfusion mismatching due to
decreased functional residual capacity, decreased cardiac
output, pulmonary embolism, aspiration, pulmonary
edema, bronchospasm, and pneumothorax are all
potentially correctable causes of hypoxia and possible
cardiac dysrhythmias (Mandel, 2002).
 Alveolar hypoventilation likewise may lead to hypercarbia
that in turn may be a factor in tachycardia and
hypertension, both of which may be deleterious to the
patient with coronary artery disease.
 The treatment is to ensure adequate ventilation by
determining the cause of the abnormality and correcting it.
6. BRADYCARDIA
 A sinus rate of less then 60 bpm might be perfectly
acceptable in a young, athletic patient who arrives in the
PACU after a minor surgical procedure; yet this rate might
signal more ominous cardiac dysrhythmias in other
patients.
 This underscores the importance of knowing the pre-
procedure baseline, or what is normal for this patient. It is
imperative to ascertain the cause of a slow dysrhythmia,
and when it is pathogenic, to correct it.
 One asymptomatic heart rate (<60 bpm), for example, may
be the result of increased vagal tone, as seen after
administration of anticholinergic medications.
 This category of medications, anticholinergics, is
frequently used to reverse the effects of neuromuscular
antagonists often used in general surgical procedures.
 If the patient is hemodynamically stable, careful
observation may be all that is necessary. Other treatment
options include re-administration of any anticholinergic
medications given earlier.
 Bradycardia may also be caused by arterial hypoxemia
and impending cardiac arrest, in which case adequate
oxygenation is vital.
9
 Bradycardia can be a compensatory mechanism used by
the body to relieve unrecognized elevated intracranial
pressure (ie, the Cushing's reflex).
 Thus bradycardia seen in response to hypertension may
occur to ensure adequate cerebral perfusion pressure.
The treatment for bradycardia in this situation is
normalization of intracranial pressure.
 Finally, bradycardia may represent a physiologic response
to hypothermia, and careful rewarming of the patient
should be undertaken.
 When the heart rate slows past a point of productive
perfusion, ectopic beats—either atrial or ventricular
premature depolarizations—begin to appear. The
presence of ectopy alone does not necessarily imply
underlying cardiac disease.
 Ectopic beats may, however, be associated with
myocardial pathology and are often associated in the PAC
setting with electrolyte imbalances, hypoxia, acid-base
abnormalities, and hypertension.
 They may be side effects from certain medications such
as digitalis toxicity, or more rarely may be caused by
endocrine disorders such as thyrotoxicosis.
 Hypokalemia and hypocalcemia are the more common
electrolyte abnormalities associated with ectopic rhythms,
and should be suspected and tested for, particularly in
patients who experienced excessive diuresis
intraoperatively, are alkalotic, or have received numerous
blood transfusions.
 Management includes measurement of electrolytes,
correction of acid-base abnormalities, and electrolyte
replacement when indicated.
 Transvenous pacing should be available for use in the
presence of symptomatic bradycardia that is not
responsive to electrolyte replacement, supplemental
oxygen or conventional pharmacologic treatment.
7. FLUID AND ELECTROLYTE COMPLICATIONS
 Complications due to fluid and electrolyte imbalances
occur primarily in older or debilitated patients, in
hypertensive patients pretreated with diuretics, in diabetic
and neurosurgical patients, and in those who have
undergone long procedures with large fluid shifts.
 Hyponatremia, hypocalcemia, and hypermagnesemia may
all work to delay a return to full consciousness.
 Any abnormal findings in these higher-risk patients
warrant immediate measurement of electrolytes and
prompt correction of abnormalities.
HYPONATREMIA
 Hyponatremia (often referred to as water intoxication) is
most often due to the syndrome of inappropriate
antidiuretic hormone (SIADH) release, although free
water absorption during such procedures involving large
amounts of irrigant such as transurethral resections of the
prostate (TURP) can also be a cause.
 SIADH can be associated with stress, general anesthesia,
positive pressure ventilation, the presence of pulmonary
carcinoma, or diseases of the pituitary system.
 Hyponatremia can also occur as a complication after
major head injury, when cerebral salt-wasting syndrome
may occur.
 Treatment of hyponatremia includes diuresis with
furosemide IV (Lasix) and, in an emergency situation,
infusion of hypertonic saline.

HYPOCALCEMIA
 Hypocalcemia occurs when total serum calcium levels fall
below 4 to 5 mEq/L. Causes include hepatic failure,
massive volume replacement, acute pancreatitis,
hypoparathyroidism, and endstage renal disease.
 Acute decrease in ionized calcium is associated with
extreme hyperventilation, bicarbonate injection, and the
rapid infusion of citrated blood (in this instance, calcium
remains present, yet is chelated or bound into an
unavailable form).
 Signs and symptoms include confusion, seizures,
hypotension, prolonged QT wave, and muscle spasm
(including laryngeal muscle spasm).
 Treatment requires correction of hyperventilation and
replacement with calcium chloride.
HYPERMAGNESEMIA
 Hypermagnesemia (greater than 2.5 mEq/L) tends to
occur most commonly in eclamptic patients treated with
magnesium sulphate as well as those with endstage renal
disease.
 Symptoms include suppression of deep-tendon reflexes,
sedation, and coma. Cardiovascular collapse occurs at
levels over 10 to 15 mEq/L.
 Treatment involves discontinuation of exogenous sources,
support of cardiorespiratory function, and intravenous
calcium.
8. ACUTE PAIN COMPLICATIONS
 Intense, uncontrollable postoperative pain is
problem that should not occur.
 A multitude of pain-control medications and techniques,
including epidural and intraspinal opioids, intercostal nerve
blocks, interpleural analgesia, and PCA (patient-controlled
analgesia), can be used to provide a postsurgical
experience with no more than slight pain for the majority of
patients.
 These measures can be augmented by the addition of
nonpharmacologic interventions for the management of
pain that include the application of cold or ice, proper
immobilization/positioning, effective pre-education, and re-
education regarding the control of pain and relaxation.
 The presence of intense postsurgical pain worsens all
other postoperative complications.
 Deep breathing and activity are restricted, which increases
the risk of atelectasis, pneumonia, and deep-vein
thrombosis.
 Tachycardia occurs in response to pain.
 Fluid shifts and physiologic responses are altered by
intense pain.
 The early use of appropriate analgesia reduces the
number and severity of most immediate postoperative
problems.
 Types of analgesic agents include nonsteroidal anti-
inflammatory drugs (NSAIDs) and opiates. Unlike opiate
analgesics that have an effect on the central nervous
system, NSAIDs act mostly at peripheral sites, inhibiting
the action of prostaglandins via antagonism of the cyclo-
oxygenase (COX) enzyme. This is an enzyme required in
the synthesis of prostaglandin, a sensitizer of peripheral
nociceptors.
 Ketorolac (Toradol) is an NSAID finding frequent
postsurgical use. In the PACU it is most frequently given
IM.
 The best time for planning postprocedural analgesia is
before administering the anesthesia.
 This allows time for pre-procedure patient instruction and
assurance, which will greatly reduce anxiety levels.
 It also allows for decisions about the use of narcotics
during the procedure and plans for placement of
postsurgical pain control measures (if indicated) before the
anesthetic agents are reversed or allowed to wear off.
 Most opioids can also be given intermittently by the
intramuscular route. This route should not be used in
hypovolemic, hypotensive patients because cardiac
output and muscle perfusion may be impaired, negating
the benefit of this route of delivery.
 Standard dosing for morphine is 0.15 mg/Kg, and for
meperidine 1.5 mg/Kg, although these doses tend to be on
the conservative side and may not be adequate for good
postoperative pain relief.
 Patient-controlled analgesia (PCA) allows the patient to
self-administer potent analgesics.
 Features central to PCA include an adequate loading dose
initiated at the time the system is prepared, an incremental
dosage scheme, with a lockout interval and time period
maximum to prevent excessive dosing. Computer
technology permits programming, storage, and retrieval of
a data.
 Patient-controlled analgesia may be used in conjunction
with oral medications and, less commonly, by the epidural
route.
 Temperature Regulation Complications
 Hypothermia—is a common postoperative problem.
Hypothermia may be caused by a number of factors,
including low ambient temperatures in procedure areas,
the inability to regulate internal temperatures effectively
due to the effects of anesthesia, the exposure of internal
"wet" membranes to evaporation, and the infusion of cold
fluids.
 Decreased internal temperature may have the following
effects:
 Impairment of the immune system
 Increase in the incidence of infection
 Increase in the rate of blood loss, leading to the need for
transfusions
 Increase in the incidence of myocardial infarction
 Prolongation of the need for mechanical ventilation
 Decrease in anticipated drug metabolism
 Increase in mortality rates
9. HYPOTHERMIA
 Practical means to prevent hypothermia include the use of
warming measures, both intraoperatively and in the
PACU.
 These measures are simple, effective, and are cost
effective for the patient as well as the facility promoting
their use.
 One practical method of initiating warming is to wrap the
patient in heat-retaining materials (instead of paper
drapes), especially around the head.
 The next step is to use warm air/forced air devices to aid
in heat retention and re-warming.
1
 The pre-warming of fluids, especially intravenous and
irrigation fluids that will be used in and on the patient are
other practical, cost-effective measures for decreasing
hypothermia post procedure.
 Children are particularly prone to heat loss because of
their relatively large body surface to total weight ratio.
 After even short procedures, their internal temperature
may be markedly reduced.
 Maintenance of normothermia is important in children who
have undergone tonsillectomy, for example, when the risk
of postoperative bleeding is ever present.
 Remember that premature and small infants are unable to
shiver and thereby increase their metabolism to cope with
heat loss.
 They can be kept warm with the use of conduction,
radiation, and convection.
10. MALIGNANT HYPERTHERMIA
 Malignant hyperthermia (MH) is a rare yet present
danger in PAC.
 Malignant hyperthermia is caused by a genetic disorder
and magnified by stress. It can be triggered by any volatile
anesthetic (eg, chloroform, ether, Halothane, Enflurane,
Isoflurane, Sevoflurane, Desflurane) as well as by some
muscle relaxants (eg, Suxamethonium).
 Malignant hyperthermia is a life-threatening disorder,
however with the use of modern techniques and alert staff,
mortality has been greatly reduced.
 The symptoms of MH include hyperventilation,
tachycardia, increasingly high temperatures, marked
metabolic acidosis, sweating, and decreased oxygen
saturation.
 Laboratory signs include hyperkalemia, raised creatine
kinase and myoglobinuria caused by damage to the cell
membranes.
 Treatment includes immediate cooling, stopping
administration of the suspected triggering agent, placing
the patient on 100% oxygen, establishment of more
intravenous access routes, and aggressive invasive
monitoring.
 Further treatment includes administration of dantrolene
and the correction of acid-base abnormalities.
 Without treatment, an episode of MH can progress to
cause kidney damage, internal bleeding, massive muscle
destruction, brain swelling, and death due to cardiac arrest
and concurrent multiple organ failure.
11. ENDOCRINE COMPLICATIONS
 Endocrine complications in post anesthesia care fall
mainly into three categories:
 Diabetic emergencies
 Acute adrenal insufficiency (adrenal or Addisonian crisis)
 Thyroid crisis (thyroid storm)
 Adrenal and thyroid complications in the acute
postoperative area are rare. Most common by far are
endocrine problems related to diabetes.
DIABETES
 The stress of surgical procedures (including prior
emotional stress, the effects of general anesthesia, and
the trauma of the procedure) can markedly increase
plasma glucose in diabetic patients and induce diabetic
ketoacidosis (DKA) in type I diabetes mellitus patients.
1
 In individuals who normally take one or two daily injections
of insulin, one-third to one-half the usual morning dose
can typically be given in the morning before the procedure
and an IV infusion of 5% glucose in either 0.9% sodium
chloride solution or water at a rate of 1L (50 g of glucose)
over 6 to 8 hours should be considered for use during the
procedure
 After the operation, plasma glucose and the plasma
reaction for ketones must be checked. Unless a change in
dosage is indicated, the preoperative dose of insulin is
typically repeated in the PACU and the glucose infusion
continued.
 Plasma glucose and ketones are monitored at 2- to 4-hour
intervals, and regular insulin is given every 4 to 6 hours as
needed to maintain the plasma glucose level between 100
and 250 mg/dL (5.55 and 13.88 mmol/L).
 This is continued until the patient can be switched to oral
intake and returned to a more typical 1- or 2-dose insulin
schedule (Merck, 2005).
 Hyperosmolar, nonketotic coma (>1000 mg/dL glucose) is
a rare cause of hyperglycemia caused by a disturbance of
the thirst mechanisms that occurs most frequently in older,
debilitated patients or in other groups after major trauma
(usually head injury).
 Severe dehydration, coma, and seizures are common with
this process. In acute treatment, the response to small
doses of insulin (10–20 units) and intravenous rehydration
is prompt
 Diabetes insipidus (DI, or emergent diabetes) is caused by
the underproduction of antidiuretic hormone and is usually
associated with head trauma, hypophysectomy, or a
global cerebral hypoxic event.
 The diagnosis depends on the presence of polyuria (>300
mL/hr), hypernatremia, decreased urine osmolarity,
increased plasma osmolarity, decreased urine specific
gravity, hypotension, dehydration, and coma.
 Vasopressin tannate, 5 to 10 units subcutaneously, is
considered to be a specific therapy. One-desamino 8-D
arginine vasopressin (4–8 mg) (DDVAP) is usually
effective by nasal insufflation or intravenous
administration. The dose may have to be repeated (Merck,
2005).
 Insulin-dependent diabetic children and those with
endstage renal disease are very sensitive to small doses
of insulin in the perioperative period.
 The regular insulin dose should be carefully adjusted and
the blood sugar measured frequently, especially if general
anesthesia is employed and the patient is not able to
convey feelings.
ACUTE ADRENAL INSUFFICIENCY
 A significant number of patients who otherwise appear
healthy in the preoperative period actually have "limited
adrenocortical reserve" and are at increased risk for
experiencing acute adrenocortical insufficiency when
under stress. Surgery, anesthesia, and the post
anesthesia time period certainly qualify as stressful.
 An adrenal crisis is characterized by profound asthenia
(weakness), severe pain in the abdomen, lower back, or
legs, peripheral vascular collapse, and renal shutdown
with azotemia (the presence of nitrogenous bodies,
especially urea, in increasing amounts in the blood). Body
temperature may be subnormal, although severe
hyperthermia due to infection can also occur.
 Treatment should be started immediately when a
diagnosis of adrenocortical failure has been made. If the
patient is acutely ill, confirmation by an ACTH response
test should be postponed until the patient has recovered.
 Hydrocortisone 100 mg as a water-soluble ester (usually
succinate or phosphate) is injected intravenously over 30
seconds. This is followed by infusion of 5% dextrose in
0.9% sodium chloride solution containing 100 mg
hydrocortisone ester given over 2 hours.
 Additionally, 0.9% sodium chloride is given until
dehydration and hyponatremia have been corrected.
Serum K may fall during rehydration, requiring careful
replacement.
 Hydrocortisone therapy is typically given continuously to a
total dosage in 24 hours of more than 300 mg. Restoration
of blood pressure and general improvement may be
expected within one hour after the initial dose of
hydrocortisone.
THYROID STORM
 Thyroid storm is a life-threatening emergency requiring
prompt and specific treatment. It is rare in children.
 It is characterized by the abrupt onset of florid symptoms
of hyperthyroidism, with some exacerbated symptoms and
atypical signs.
 Signs and symptoms associated with thyroid storm include
fever, marked weakness, and extreme restlessness, with
wide emotional swings, confusion, psychosis, and even
coma.
 Tachycardia, widened pulse pressure, tremor, abnormal
eye movements, atrial fibrillation, increased sweating,
hypersensitivity to heat, and palpitations, fatigue, and
occasionally diarrhea may also be present.
 Many symptoms of acute hyperthyroidism are similar to
those of adrenergic excess or adrenal crisis.
 Older adults, particularly those with toxic nodular goiter,
may present atypically with apathetic or masked
hyperthyroidism.
 One of the most frustrating aspects of acute
hyperthyroidism is that the patient may present with
cardiovascular collapse and shock initially, bypassing
clues as to what is actually occurring.
 Thyroid storm results from untreated or inadequately
treated underlying hyperthyroidism and may be
precipitated by infection, trauma, a surgical procedure,
embolism, diabetic acidosis, or toxemia of pregnancy or
labor.
 Propranolol is often indicated in the treatment of thyroid
storm. It rapidly decreases heart rate, usually within 2 to 3
hours when given orally and within minutes when given
intravenously.
 Propranolol is also indicated for the prompt management
of tachycardia found in other forms of hyperthyroidism
(including thyroiditis), and especially in older patients with
no history of congestive heart failure, since it ordinarily
takes several weeks to get relief from the antithyroid
drugs.
 Calcium channel blockers may be useful for controlling
tachyarrhythmias in patients in whom other forms of
blockers are contraindicated.
 The administration of iodine should be initiated in the
acute setting. One gram of sodium iodide by intravenous
infusion over 24 hours is recommended.
 Propylthiouracil is also preferred for the treatment of
thyroid storm because the typical dosage (800–1200
1
mg/day) partially blocks the peripheral conversion of T4 to
T3.
 Correction of underlying dehydration and electrolyte
imbalances, along with cooling in the presence of
hyperthermia, should also be instituted.
 Once the acute thyroid crisis is over, treatment inevitably
consists of reduction of the thyroid gland by iodine isotope
therapy or surgery (Merck, 2005).
12. MEDICATION COMPLICATIONS
 When a complication arises in the post anesthesia care
unit and no clear causative factor can be determined, think
drug interaction.
 There are numerous drug interactions that can lead to
toxicity. Drug interactions can also alter the desired
therapeutic end point, or, at the very extreme, be life-
threatening.
 Significant drug-to-drug interference is usually by means
of one of the following mechanisms:
 Increased difficulty of absorption
 Interference with distribution
 Problems with metabolism
 Problems with elimination
CASE STUDY
 A 36-year-old female patient has just undergone a deep-
vein stripping of her left leg. The case was managed under
general anesthesia, by patient request, which for the most
part was uneventful except for some mild tachycardia and
hypertension. Intraoperatively, she was given several
bolus infusions of propranolol and midazolam. Pre-
anesthetic assessment noted that she had been taking
many over the counter remedies for weight control.
Postoperatively she is awake and slightly dizzy; her blood
pressure is 70/40 with a pulse of 100 and oxygen
saturation of 94% on 2 L via nasal cannula.
CASE DISCUSSION
 A fluid bolus of 500 cc, 0.9 saline was given while further
assessment of the patient's status was made. No
remarkable physiologic findings were noted, although
initial concern was present for blood clot shower due to
the nature of her procedure. Obvious complications ruled
themselves out as the patient's blood pressure and pulse
stabilized during the first hour of PAC monitoring and her
recovery proved completely unremarkable from that point
on.
 Retrospective analysis and questioning revealed that the
patient was currently taking a large dose of the herbal
remedy ma huang, a Chinese plant containing ephedra, as
part of her self-diet regimen. Preoperatively, the staff had
not asked the patient to list any vitamins and herbal
supplements she was taking, and the patient had
assumed that any such items had no relation to the
surgery. She had taken her regular morning supplements
on an empty stomach immediately prior to the procedure.
13. MATERNAL COMPLICATIONS
 In maternal/newborn care, the challenge is more than
doubled.
 Remember, a maternal patient may need anesthesia or
heavy sedation at a time other than delivery!
 When anesthesia is given for surgical or special
procedures other than birth, special monitoring of mother
and child is likely to be required during the immediate post
anesthesia period (Norwitz & Park, 2005).
 During pregnancy, the cardiovascular system changes to
accommodate the increased demands placed on it by
child and mother.
 At term, blood volume has increased by more then 40%.
Of that increase, the plasma volume change is greater
than that of the red cells, resulting in an anticipated
lowering of hemoglobin levels and a tendency toward the
complication of dilutional anemia.
 Cardiac output adjusts during the second trimester to meet
the approximately 20% increase in oxygen consumption
as the mother breathes for two, and exceeds a 50%
increase from baseline during the time of labor.
 These changes are reflected in a faster heart rate and
increased peripheral vascular resistance with a decrease
in the diastolic blood pressure.
 Uterine displacement leads to a tendency for compression
of the inferior vena cava as well as the aorta (especially
when the mother is supine), and may result in episodes of
maternal hypotension and fetal distress (Norwitz &
Park, 2005.)
 The increase in blood component plasma volume
accompanying pregnancy results in an effective decrease
in the viscosity of the maternal blood.
 Perhaps as a design accommodation to this, the
coagulation factors I, VII, X, and XII are found to be at
increased levels, especially in the final stages of term
(Norwitz & Park, 2005.)
 The increase in coagulation factors produces a tendency
toward hypercoagulability.
 This creates a need for increased vigilance in the PACU to
prevent and detect coagulation complications such as
deep vein thrombosis and emboli.
 Blood volume changes also shift the standards of
awareness for the complication of hypotension.
 In the presence of an anticipated increase in heart rate,
lowering of hemoglobin, and increase in cardiac output,
the definition of hypotension for the maternal patient is a
systolic pressure below 100 mm Hg, or 20% lower than
pre-anesthetic level (30% in hypertensive patients).
 Remember that maternal patients are already disposed
toward dilutional anemia. Large amounts of fluids must be
used with great caution
 Respiratory changes also occur in the maternal patient.
 Capillary engorgement through the respiratory tract trends
toward the point of edema, and increased fragility of the
mucous membranes can result in severe hemorrhage from
nasogastric or endotracheal tube insertion.
 The changes resulting from pregnancy result in an
increase of alveolar ventilation of around 70%.
 This increased ventilation leads toward respiratory
alkalosis with a compensatory change in renal excretion of
bicarbonate and correction of pH.
 All of this helps offset another complicating tendency
associated with the process of labor and potentiated with
the induction of general anesthesia: the possibility of
hypercarbia and hypoxia.
 Oxygen saturation must therefore be closely monitored
during the early stages of recovery.
 The elevated progesterone levels that accompany
pregnancy work to decrease overall gastric mobility and
food absorption while, as term approaches, lower
esophageal sphincter tension increases.
 Concurrently, gastric acidity and volume reach new highs
due to placental gastrin secretion and uterine pressures
on the gastroesophageal space. The result of these
changes is a heightened danger of vomiting and aspiration
.
 The increased risk of aspiration is just one reason regional
anesthesia is preferred for the maternal patient.
 The possible adverse effects of systemic agents on the
child is another consideration when reviewing anesthetic
options.
 However, complications can arise with regional anesthetic
agents as well. The cardiovascular changes of pregnancy
result in an engorgement of the vasculature associated
with the epidural space, increasing the potential for
puncturing an epidural vein. (On a related note,
cardiovascular changes decrease actual epidural space,
leading to a lessening of the amount of regional anesthetic
needed for effect as compared to nonpregnant patients)
(Faure, 2006).
CONCLUSION
 The immediate postoperative period in the post anesthesia
care unit is the beginning of periodic evaluation and
assessment that continues for 24 hours.
 The purpose of this time-increment assessment is to
identify problems such as sore throat, hoarseness, nerve
paresthesias, explicit recall, postdural puncture
headaches, continued PONV, and inflammation over sites
of invasive monitors. Respiratory problems requiring re-
intubation, cardiovascular instability, acute renal failure,
acute pulmonary edema, and altered mental status are
postoperative problems that require careful attention to
determine what may be contributing to the problems.
 For the staff, the use of anesthesia is an everyday
occurrence; for the patient who has undergone
anesthesia, it is unusual. The postoperative follow-up
provides the opportunity for patient education,
reassurance, treatment of any adverse events, and the
chance to ensure a positive experience for the patient in
relation to anesthetic care. The most important measure to
prevent the development of complications is good
communication among the anesthesiologist, surgeon,
consultants, and nursing staff.
