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ASA PRACTICAL GUIDELINES

FOR POSTANESTHETIC CARE


2013
SUPARNO ADI SANTIKA



A Review Article
POSTANESTHESIA CARE
Definition : Activities undertaken to manage
the patient after completion of a surgical
procedure and the concormitant primary
anesthetic

Purpose : Improved post-anesthetic care
outcome

POSTANESTHESIA CARE
Initial emergence
Transport to the PACU
Management of PACU problems
Continuous care of complications resulting
from anesthesia
Subsequent assessment (postoperative visit)

POSTANESTHESIA CARE
Focus :
Reducing post operative adverse effect
Providing uniform assessment of recovery,
monitoring and management patient safety
Improving post anesthetic quality of life
Streamlining post operative care and
discharge criteria



ASA POSTANESTHESIA CARE
ASSESSMENT AND
MONITORING
Respiratory Function :
Early detection of hypoxemia (Level A2-B
evidence)
Periodic assessment and monitoring airway
patency, respiratory rate and Oxygen
saturation (SpO2)



ASA POSTANESTHESIA CARE
ASSESSMENT AND
MONITORING
Cardiovascular Function :
Pulse, Blood pressure, ECG monitoring
Perioperative complication
Certain catagories ECG may not be necessary
Young adult w/o cardiac event
etc



ASA POSTANESTHESIA CARE
ASSESSMENT AND
MONITORING
Neuromuscular Function :
Neuromuscular blockade monitoring (B2-B
evidence)

Mental Status
POCD (Geriatric patient)



ASA POSTANESTHESIA CARE
ASSESSMENT AND
MONITORING
Temperature :
Fever Postoperative Complication
Shivering Postoperative Complication

Pain :
Pain Controlled



ASA POSTANESTHESIA CARE
ASSESSMENT AND
MONITORING
Nausea and Vomitting :
PONV

Fluid :
Assess hydration status and px fluid
management



ASA POSTANESTHESIA CARE
ASSESSMENT AND
MONITORING
Urine output and Voiding :
Identifying px w/ urine retention (B3-B
evidence)
Evaluation of px fluid management

Drainage and Bleeding:
Assess and consider blood component
replacement therapy



PROPHYLAXIS and TREATMENT
NAUSEA AND VOMITING
Antihistamine : Promethazine (A3-B evidence)
5-H3 Antiemetics : Rescue antiemetics and
Reduce vomiting (Ondansentron, Tropisentron),
Reduce vomiting (Granisentron, Dolasentron).
Newest (Palonosentron, Ramosentron A2-B
evidence)
Tranquillizer : Inapsine (Droperidol), Haloperidol
(rescue antiemetics) .. Hydroxizine, Perphenazine
(Vomiting, dizziness, anxiety, headache)
Metoclopramide
Scopolamine
Administration of Suplemental Oxygen :
Prevent Hypoxia during px transportation
Prevent Hypoxia in recovery room
(A3-B Evidence)
Treatment during Emergence and
Recovery
Normalizing Patient Temperature :
The perioperative maintenance of
normothermia and
The use of forced-air warming reduce
shivering and
Improve patient comfort and satisfaction.
Pharmacology agent for reduce shivering :
Meperidine (Agonist Opioid)
Treatment during Emergence and
Recovery
Benzodiazepines : Flumazenil (A3-B
evidence) reduce time to emerge after
sedation Nausea, BP instability,
agitation-restless, dizziness, resedation-
drowsiness


Antagonism of the Effects of Sedatives,
Analgesics,and Neuromuscular
Blocking Agents
Opioids : Naloxon (A3-B evidence) reduce
time to emerge and recovery of
spontaneous respiration after GA Not
for routine use


Antagonism of the Effects of Sedatives,
Analgesics,and Neuromuscular
Blocking Agents
Urinate before discharge : - benefits ex
ODC
Drink clear fluid before discharge : Vomit
Responsible individual to accompany them
home after discharge : agree
Minimum mandatory stay in recovery
Discharge Protocol
Practical Appraisal
COMMON COMPLICATIONS
POSTANESTHESIA
Nausea/vomiting 5%
Unexpected alterations in mental state 5%
Requirement for upper airway support 3.6%
Hypotension 3%
Dysrhythmias 2%
Hypertension, myocardial ischemia, or a
major cardiovascular complication <1%


Checklist for Evaluating Patients Before Departing
the OR and After Arriving in the PACU

Airway patency
Breathing (rate and depth)
Arterial oxygenation (pulse oximeter)
Blood pressure
Heart rate, ECG
Level of SAB or EPIDURAL
Level of consciousness


CARE IN THE PACU
Admitting the Patient to the PACU
Supplemental oxygen
Monitoring devices
Pulse oximeter
ECG
Temperature
BP
Routine evaluation
Anesthesiologist provides complete report
Anesthesiologist leaves only when satisfied that
patient can be cared for by the receiving
personnel
REPORT ON ADMITTING A
PATIENT TO THE PACU
Patients name

Brief medical history
Significant comorbidities (asthma, angina)
Drugs
Allergies

Surgery
Site
bleeding

Anesthetic
Anesthetic agents, sedatives, narcotics
State of alertness
Muscle relaxants, recovery
Expected vital signs

Summary of fluid balance
Blood and fluids given
Urine output
Blood loss


Expected problems and plans
Oxygen required
Fluid therapy
Pain management
Any alterations in usual PACU
discharge criteria

COMMON PROBLEMS
IN THE PACU
DELAYED AWAKENING
Acute metabolic disorders
Hypoxia
Hypercarbia
Hypoglycemia
Other electrolyte disorders
Water intoxication

Residual neuromuscular
blockade

CNS disorders
Stroke
Post-anoxic encephalopathy

Residual effects of anesthetics,
sedatives
Other medications
Premedicants
Central anticholinergic syndrome:
scopolamine, atropine
Illicit drugs
Cimetidine

Hypothermia

Preexisting coma or obtundation

Interpatient viariation in response
to anesthetics

AGITATION AND DELIRIUM
Hypoxemia or airway
obstruction
Hypercarbia
Cerebral ischemia
Pain
Full bladder
Incomplete reversal of
neuromuscular blockade
Withdrawal from alcohol or
other drugs

Central anticholinergic syndrome
(scopolamine, atropine, tricyclic
antidepressants, antihistamines,
butyrophenones or
phenothiazines)
Residual anesthetics or sedatives
(barbiturates, ketamine)
Senile dementia
Emotional or anxious state prior to
anesthesia
Patients who awaken restrained
(e.g. casts)


PAIN
Operative site
Muscle spasm
Bladder distension
Musculoskeletal
Exacerbation of arthritis
Injury from positioning

Tight cast or dressing
Phlebitis, infiltration of IVF
Angina
Corneal abrasion

NAUSEA AND VOMITING
History of nausea or
vomiting after
previous operations
Gastric distension
Ileus
Bowel obstruction
Prolonged or inept mask
ventilation
Full stomach before
surgery
Opioids
Type of surgery
Ophthalmologic procedures
Laparoscopy
Otorhinologic procedures
especially inner ear
Abdominal operations

RESIDUAL NMB
Any patient with unexplained upper airway
obstruction, hypoventilation, or delayed awakening
after a general anesthetic should be evaluated for
residual neuromuscular blockade.

Head or leg lift test for 5 seconds

Treatment additional neostigmine
AIRWAY OBSTRUCTION
Causes
Somnolence
Residual weakness
Obtunded airway reflexes
Upper airway edema
Sleep apnea
Obesity
Partial airway obstruction preoperatively

Signs
Noisy breathing
Dyspnea
Cyanosis
Hypoxemia
CV abnormalities
Tracheal tug
Nasal flaring
Rocking motions of the chest
Treatment
Repositioning the head and
neck
Oxygenation
Jaw thrust
Nasal and oral airways
Tracheal intubation
HYPOXEMIA
Atelectasis
Aspiration pneumonitis
Decreased FRC
Pulmonary edema
Pneumothorax
Pneumonia
Splinting from incisional
pain
Increased oxygen
consumption (fever,
shivering)
Decreased cardiac output
Depression of ventilatory
responses to hypoxemia
by residual anesthetics
Depression of ventilatory
responses to hypercarbia
by opioids
RESPIRATORY DEPRESSION
Causes
Residual drug effects
Airway obstruction
Lung disease (COPD)
Increased CO2
production (shivering,
fever)
Opioids
Treatment
Oxygenation
Stimulation
Assisted or controlled
PPV
Naloxone (40-80mg) if
due to opioids
HYPERTENSION/
HYPOTENSION
Hypertension
Preexisting HTN
Anti-HTN medication not
taken
Pain
Distended bladder
Volume overload
Emergence delirium
Hypoxemia, hypercarbia
Hypothermia with
vasoconstriction
Hypotension
Hypovolemia due to
unreplaced intraoperative
losses, continuing bleeding
and third space losses
Residual effects of SAB or
epidural anesthesia by
blunting sympathetic
responses
Occult hypovolemia after
opioids
LVF
Sepsis
Pulmonary embolus
Tension pneumothorax
HYPOTHERMIA
Effects
Slows emergence
Impairs organ function
and coagulation
Exacerbates HTN
Increases oxygen
consumption and
demands in cardiac
output
Management
Warm the OR to 26C
Use warming blankets
or active heating
devices
Warm IVFs

FEVER
Less common than hypothermia
Common case: pulmonary atelectasis
Less common: febrile reactions to drugs
and transfused blood
Rare but grave: onset of MH
ASA SUMMARY TREATMENT
RECOMMENDATIONS
Nausea and vomiting
Antihistamines, 5-HT3 antagonists,
droperidol, dexamethasone,
scopolamine or metoclopramide.
Supplemental oxygen for patients
at risk of hypoxemia.
Fluids
Postoperative fluids should be
managed in the PACU.
Certain procedures may require
additional fluid management.
Temperature
Normothermia should be maintained.
Forced-air warming systems are most
effective for treating hypothermia.
Pharmacologic agents for the reduction
of shivering
Meperidine is recommended.
Antagonism of the effects of
sedatives, analgesics, and NMB
Antagonism of benzodiazepines
Antagonists should be available.
Flumazenil should not be used
routinely.
Flumazenil may be administered to
antagonize respiratory
depression and sedation.
Antagonism of opioids
Antagonists (e.g., naloxone) should be
available but should not be used
routinely. Naloxone may be
administered to antagonize respiratory
depression and sedation.
Reversal of neuromuscular blockade
Specific antagonists should be
administered for reversal of
residual neuromuscular blockade as
indicated.

After reversal, patients should be
observed to ensure that
cardiorespiratory depression does not
occured.

ROUTINE DISCHARGE
CRITERIA FROM PACU
Vital signs satisfactory and stable
Return to postoperative mental state
Adequate pain control
Immediate treatment of any complications
Adequate treatment of nausea/vomiting
Adequate function of all drains, tubes, catheters
Surgical bleeding controlled or treated
Postoperative orders reviewed and implemented
Laboratory studies needed immediately obtained
and results reviewed
ASA SUMMARY OF RECOVERY AND
DISCHARGE CRITERIA
GENERAL PRINCIPLES
Medical supervision of recovery and discharge is the responsibility of the supervising practitioner.
The PACU should be equipped with appropriate monitoring and resuscitation equipment.
Patients should be monitored until appropriate discharge criteria are satisfied.
Level of consciousness, vital signs, and oxygenation (when indicated) should be recorded at
regular intervals.
A nurse or other individual trained to monitor patients and recognize complications should be in
attendance until discharge criteria are fulfilled.
An individual capable of managing complications should be immediately available until discharge
criteria are fulfilled.

GUIDELINES FOR DISCHARGE
Patients should be alert and oriented. Patients whose mental status was initially abnormal should
have returned to their baseline.
Vital signs should be stable and within acceptable limits.
Discharge should occur after patients have met specified criteria. Use of scoring systems may
assist in documentation of fitness for discharge.
Outpatients should be discharged to a responsible adult who will accompany them home and be
able to report any postprocedure complications.
Outpatients should be provided with written instructions regarding post procedure diet,
medications, activities, and a phone number to be called in case of emergency.

ALDRETE SCORING SYSTEM
ELEMENTS OF
POSTANESTHETIC VISIT
Overall patient satisfaction. Did
the perioperative course match
expectations? What should be
done differently next time?

What does the patient
remember about the induction
or about being in the OR? This
may reveal intraoperative
awareness.

Adequacy of pain relief.

Review outcome of any special
problem such as nausea and
vomiting, HTN, back pain.

Objectives
Alerts anesthesiologist to
complications that can be
treated such as PDPH,
dental injuries, backache,
intraoperative awareness

Improvement of care

Corrects misconceptions/
misunderstandings that
might lead to
dissatisfaction/litigation

TREATMENT OPTIONS IN RELATION TO MAGNITUDE OF
POSTOPERATIVE PAIN EXPECTED AFTER SURGERY
FACTORS INFLUENCING
ANALGESIC REQUIREMENTS
Age: elderly patients request smaller doses.
Sex.
Pre-operative analgesic use.
Past history of poor pain management.
Coexisting medical conditions such as substance abuse or
withdrawal, hyperthyroidism, anxiety disorder, affective
disorder, hepatic or renal impairments.
Cultural factors and personality. (e.g., patients vary from
being intolerant of any discomfort to surprising self-control or
patients consider pain to be a normal part of life).
Preoperative patient education (can improve expectations,
compliance and ability to effectively interact with pain
management techniques).
Site of operation: thoracic and upper abdominal operations
are associated with the most severe pain.
Individual variation in response and pain threshold.
Attitude of the ward staff.



For all the happiness mankind can gain,
It is not in pleasure, but in rest from pain.
John Dryden (1631-1700)