Beruflich Dokumente
Kultur Dokumente
UNIT (PACU)
Department of Anesthesiology &
Reanimation
School of Medicine, Malahayati University
Design of PACU
Near the operating room and other Intensive Care facilities
Open ward (to facilitate observation of all patients
simultaneously)
well lighted (day light)
Pulse oxymetri
ECG
Equipment
BP monitor
Warming/cooling blanket
Emergency trolley
outlets : oxygen, electrical, suction
minor set
infusion/syringe pump
Before world war II
Post operative death after anesthesia and
surgery is high
This period is characterized by relatively
high incidence of potentially life threatening.
Respiratory and circulatory complications.
After world war II
Success of RR factor in evaluation of
modern ICU/PACU
Staffing
Nurses - trained in care of emerging
Patients ( ACLS)
- I Nurse for 2 Beds ( Patients )
Medical direction of an Anesthesiologist Coordinated to
Surgeon and any consultants
Emergence from Anesthesia
Because post operative is a time of great physiologic stress.
Ex…….. - Airway obstruction
- Shivering
- Vomite ...etc.
Delayed Emergence
When the patients fail to regain consciousness 60-90 minute
following general anesthesia ( G.A.)
The causes
Residual Anesthetic
Sedative
Prolong effect of opiate
Hypothermia
Metabolic Disturbances
Perioperative stroke (rare)
Post op/post anesthesia Management
Monitoring: - vital sign - BP
Pulse/HR
RR
- Oxygen supplementation
(SpO2)
- Temp
- Sensory and motor level
(Regional Anesthesia)
Pain control
- parenteral
- Regional anesthesia
- Nerve Block
Agitation/Restlessness
- cause ? (hipoxemia, acidosis etc)
Nausea and vomiting
cause ? hypotension by
- regional anesthesia
- opioid
- vagal tone
Shivering
cause ?
- Unwarmed I.v. fluids
- Exposure of large wound
- AC
- Hyperthermia
- Metabolic acidosis ect
Complications in PACU
1. Airway obstruction
- Unconscious patients
tongue
falling
back against the posterior
pharynx
- Larynx spasm
- Glottic edema etc
2. Hypoventilation
- Defined as PaCO2 > 45 mmHg
pH < 7,25
- Causes
- Residual depressant effect of
anesthesia agents
(overdose)
- In adequate reversal
- Severe pain
- Tight abdominal dressing
- CO2 production is high
3. Hypoxaemia
Defined as PaO2 < 70 mmHg
Causes
- Hypoventilation
- Oxygen consumption
- FRC
- Lung - edema
4. Hypotension
- Defined as A 20-30% reduction
of BP
- Causes
- Hypovolemia
- Ventricular
dysfunction
- Impaired cardiac filling
5. Hypertension
Defined as BP > 20-30% of base
line
Causes
Sympathetic activation
- pain
- hypercapnia
6. Arrhythmia
- Hypercarbia
- Electrolyte disturbances
- Residual effects of
cholinesterase inhibitor
Discharge criteria
- must be evaluated
- after 60 minutes in the PACU
_____________________________________
Parameters Value
____________________________________
color - pink 2
- pale 1
- cyanotic 0
_____________________________________
Respiration - Breathe deeply & cough 2
- Shallow but adequate 1
- apnea 2
_____________________________________
Circulation
BP within 20% of normal 2
20-50% 1
50% from normal 0
_________________________________________________
Consciousness
- awake/alert 2
- arousable 1
- no response 0
_________________________________________________
Activity
- move all extr 2
- move 2 extr 1
- no movement 0
INTENSIVE CARE UNIT (ICU)
- Multi disciplinary
- As intensive care with potentially life
threatening illness
- Supporting therapies
- neurologic
- cardiovascular/hemodynamic
- Pulmonary/respiratory
- Electrolyte/metabolism
- Nutritional
NEUROLOGIC SUPPORT
- CBF is constant auto regulation
at range of BP (MAP 50-
150mmHg)
- Injury losses of ability
autoregulation
- CBF related to CPP
(CPP = MAP-ICP)
ACUTE CNS INJURY
- Ischemia (focal or generalize)
- Structural distortion of brain
- Scoring – GCS
- CNS support is focused on
- optimizing systemic & cerebral B.F
- normalizing ICP
-Immediate concerns
- airway/ventilation/oxygenation
- hemodynamic issues
-Hypotension (loss of automatic control)
- Hypertension (hyper adrenergic state)
- Cardiac dysfunction
- Seizures control (metabolic/infections)
- Neurologic exam
- Is there a surgical lession ?
- GCS
- Laboratory
- CT Scan
SUPPORTIVE CARE
- General treatment
- Oxygenation
- Correct anemia
- Hemodynamic stability
- Establish normovolemia
- Control hyperthermia
- Control seizures
- control pain
- Avoid agitation/shivering
- correct metabolic abnormalities
-Control ICP
- CSF (volume reduction)
- Hyperventilation
- Osmotic agent
- Barbiturate
- Head position
- To be prevent vasospasm
- Steroid (?)
CARDIOVASCULAR/HEMODYNAMI
C SUPPORT
-Major determinants of cardiac output (C.O)
- Heart rate & Contractility
- Blood Vessels
- Volume Intra vascular
- Pre Load
- After Load
- Oxygen Delivery
- C O = HR x 3 V
*SV Is Determined By
- Preload
- After load
- Contractility
* Clinical Measurements
- Preload - Echo Cardiography
- PCWP
After load = SVR
= MAF - CV x 80
C. O
Contractility = ECHO = EF
• Oxygen Delivery (D O2)
D O2 = Ca O2 x C O x 10
= (HB x 1.34 x Sa O2)
+(PaO2 x 0,031) x C. O x 10
SHOCK
* Characterized BV
- Organ Blood Flow that Is Inadequate
to meet Tissue Demands
* Four Categories Of Shock
1. Cardiogenic Shock
- Co
- PCWP
- SVR
2. Hypovolemic Shock
- CO
- PCWP
- SVR
3. Distributive Shock
- CO N/
- PCWP N /
- SVR
4. Obstructive Shock
- CO
- PCWP
-SVR
MANAGEMENT OF SHOCK
- Increasing C.O
- Therapy Arrhythmias
- To Manage - Pre Load
- After Load
- Fluid
- Improve Contractility
- Optimize Oxygen Delivery
- Hemoglobin
- P a O2 (FiO2 & Lung Function)
- Vaso Pressor & Inotropic Agent
- Dopamine. etc
- Antibiotic
- Decrease Oxygen Demand
Respiratory Support
One of Most Common Disorder Leading to 1cm
Admission is ARF (Acute Respiratory Failure)
ARF. - When the Pulmonary system is no
longer able to meet the metabolic
demands of the body
Clinical - Arrhythmias
- Muscle Weakness
- Paralysis. etc.
TREATMENT
- Underlying cause
- Stop Offending Drugs
- Limitation of Potassium
- Correcting
- ECG Abnormalities are present
- CaCl2 10 % 5-10 ml (i.v.5-10 mnt)
- Sodium Bicarbonate
1 Meg /Kg BW /I.V 5-10 mnt.
- 10 IU RI. In 10 Ml Dext.50 %/IV/10’
- Dialysis
3. SODIUM (N 135 - 145 mEq/L)
1. Hyponatremia (Na + < 135 mEq/L)
Causes
- Excess Secretion of ADH
- Non Sodium Solute Infusion
Clinical.
- CNS Disturbances
- Muscular Disturbances
TREATMENT
- Treating the Underlying Disease
- Stop Offending Drugs
- Correcting
- Restricting free water intake
- Increasing free water clearing
- Loop diuretic
- Replace with saline 5 %
- Limit 15 mEq/L in first 24
hours
2. HYPERNATREMI (Na + > 145 mEq/L)
Cause - Intracellular volume Depletion
with
- A Loss of free water
- Excessive sodium intake
Clinical
- CNS
- Muscle
TREATMENT
Underlying Causes
Free water Repletion
L = 0,6 x wt [( Na1 /Na2)-1]
L = Water deficit
Na 1 = Normal Sodium Level
Na 2 = Measured
Wt = KS