Dischare criteria from PACU by- Drn.pptx

Ghhh

1. DISCHARGE CRITERIA FROM PACU Presented by : dr Shivangi giri Moderator : dr pratiksha gogia Total no. of slides : 30 1

2. Introduction Post anaesthesia care unit is the area designated for the monitoring and care of patients who are recovering from the immediate physiologic derangements produced by anaesthesia and surgery . In 1949 having a PACU was considered a standard of care 2

3. Need for PACU Emergence from general anesthesia and surgery may be accompanied by a number of physiologic disturbances that effect multiple organ systems. Most common are postoperative nausea and vomiting (PONV), hypoxia, hypothermia and shivering, and cardiovascular instability . Many d eaths that occur due to complications( during emergence from anesthesia & surgery) are preventable with proper post-anesthetic care . PACU were established To provide specialized Post anesthetic care To reduce post operative mortality rate To enable a successful and faster recovery of patients post operatively To provide quality care and to reduce length of hospital stay 3

4. ASA Standards for PACU All patients who have received general anaesthesia , regional anaesthesia , or monitored anaesthesia care shall receive appropriate post –anesthesia management The patient transported to the PACU shall be accompanied by a member of the anaesthesia care team that is knowledgeable about the patient’s condition. The patient shall be continually evaluated and treated during transport with monitoring and support appropriate to the patient’s condition Upon arrival in the PACU, the patient shall be reevaluated and a verbal report provided to the responsible PACU nurse by the member of the anesthesia care team who accompanies the patient . The patient condition shall be evaluated continually in the PACU. A physician is responsible for discharge of the patient from PACU 4

5. S hifting Patient F rom Operating R oom to PACU Before shifting patient from O T to PACU following should be achieved - Hemodynamic stability Clinical evaluation and complete recovery from NM blockade Maintenance of saturation Normothermia Transport from operating room to the PACU: patient should be transported with oxygen support Unstable patients should remain intubated and transported with portable monitors (ECG, SPO 2 ,&BP)and supply of emergency drugs. A qualified anesthesia personnel must attend the transfer to PACU 5

6. Routine Recovery Airway patency ,vital signs oxygenation, level of consciousness must be assessed immediately upon arrival in PACU BP,HR ,RR measurements in every 5 min for 15 min then in every 15 min . C ontinuous pulse oximetry and ECG monitoring Neuromuscular function and temperature must be assessed Anaesthesia provider should give a report to PACU care provider including Preoperative history (mental status ,any communication barrier, such as deafness ,mental disability ) Intraoperative factors (surgical Procedure ,Type of anaesthesia , Estimated blood loss, fluid replacement , U rine output etc ) Expected post operative problem Post operative instructions 6

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8. Phases of post-op unit Phase 1 Immediate recovery phase Requires intensive nursing care to detect early signs of complication Receive a complete patient record from the Operating room which decides post operative care plan It is designated for care of surgical patient immediately after surgery and patient requiring close monitoring Phase 2 Phase known as step down or progressive care unit Care of the surgical patient who has been transferred from the phase 1 post op unit Patient requiring less observation and less nursing care than phase 1 8

9. Stay in PACU Stay in PACU will vary and is dependent upon several factors Type of surgery ( patient’s response to surgery and anaesthesia ) Patient’s medical history Average length of PACU stay is 1-3 hrs During stay following are the basic care and monitoring that is to be done Monitoring vitals Checking level of consciousness & ability to respond to commands Monitoring input and output balance . Protecting airway (by proper positioning of patients head ). Assessment of the surgical site Looking for any signs of postoperative complications Post operative pain management 9

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11. Complications during emergence from Anesthesia Emergence from General Anaesthesia is ideally smooth and gradual awakening in controlled environment however problem such as airway obstruction ,shivering , agitation, delirium, PONV are frequently encountered Patient receiving spinal or epidural anaesthesia may experience decrease in BP during transport or recovery 11

12. Delayed emergence When the patient fails to regain consciousness within an expected period time after general anaesthesia . Most common cause is residual drug effect . Less common causes are hypothermia ,electrolyte disturbances, hypoxemia. Factors contributing to prolonged non depolarizing neuromuscular blockade 12

13. Post operative pain management Mild to moderate pain can be treated by- NSAIDS (acetaminophen , diclofenac etc ) Moderate to severe pain – commonly treated with oral and parenteral opioids. However opioid administration associated with adverse effect ( nausea vomiting respiratory depression , pruritus ,urinary retention ) so either carefully titrated small dose of opioid given par enterally or other opioid sparing strategies are used to manage pain. Single shot or continuous nerve blocks, wound infiltration ,field blocks , IV lidocaine infusions or continuous e pidural analgesia . 13

14. PONV (Post O perative N ausea Vomiting ) Patient who experiences nausea or has emesis within 24 to 48 hr. of surgical procedure that required anaesthesia meets the criteria for diagnosis of PONV. Patient Factors influencing PONV Women, positive history of PONV, Obese patients H/O motion sickness Surgical factors influencing PONV Duration of surgery Longer exposure to emetogenic drugs Gynecological surgery , laparoscopic surgery , ENT surgery Anesthetic factors influencing PONV Opioids Inhalational agents specially N2O Neostigmine Hypoxia 14

15. Drugs for PONV Inj Ondansetron (4mg), dexamethasone (4mg), or Inj Droperidol (1.25mg ) administered intravenously (IV) as prophylactic therapy before induction of general anesthesia are equally effective in decreasing the incidence of PONV by about 26% 15

16. Shivering and Hypothermia Most common cause of hypothermia is redistribution of heat from the body core to the peripheral compartments Anesthetic drugs decrease the shivering threshold. so shivering is commonly observed during or after emergence from general anesthesia . shivering is more related to duration of surgery &use of volatile agents. Other less common causes can be sepsis , drug allergy, transfusion reaction Intense shivering causes precipitous rise in oxygen consumption ,CO2 production and cardiac output , which may be poorly tolerated by cardiac or pulmonary disease patients Hypothermia has been associated with increased incidence of MI, arrthymias coagulopathy with increased transfusion requirements and prolonged muscle requirement Small intravenous doses of Meperidine (10-25mg) can be used to reduce shivering. Tramadol, Norepinephrine and serotonin reuptake inhibitor, has been shown to be effective in preventing post-op shivering. 16

17. Respiratory complications Most frequently encountered serious complications in PACU- Complications are related to airway obstruction, hypoventilation , hypoxemia, hypoxemia Airway obstruction Most common cause tongue fall against the posterior pharynx (often seen in OSA patient ) Other causes – laryngospasm , glottic edema ,aspirated vomitus ,retained throat pack ,secretions ,blood in the airway ,or external pressure to trachea In case od airway obstruction – paradoxical chest movements are seen Nasal airways are preferred in patient emerging from anaesthesia and having airway obstruction. 17

18. Laryngospasm – occur following airway trauma ,repeated instrumentation stimulations from secretions . It is characterized by high pitched crowing noises during ventilation (silent with complete glottis closure ) Usually laryngospasm break doing giving jaw thrust maneuver and giving positive pressure Refractory laryngospasm should be treated with small dose of IV succinylcholine(10-20mg) & PPV Glottic edema – following airway instrumentation is an important cause of airway obstruction in infants and child . IV corticosteroids (dexamethasone 0.5mg/kg, max dose 10 mg )or aerosolized racemic epinephrine (0.5ml of a 2.25% solution with 3ml of NS )is often used. 18

19. Hypoventilation – defined as a PaCO2 greater than 45mmhg (common after G.A) Severe hypoventilation signs – PaCO2 greater than 60 mmhg or arterial Ph less than 7.25 Excessive somnolence , airway obstruction ,labored breathing ,slow Respiratory Rate , tachypnea with shallow breathing, circulatory depression Hypoventilation in PACU is most commonly due to residual depressant effect of anaesthetic & analgesic agents on respiratory drive(made worse with H/O OSA ) Hypoventilation with obtundation , circulatory depression and severe acidosis (arterial blood Ph less 7.15)is an indication for the immediate and decisive ventilator and hemodynamic intervention ,including airway and inotropic support . IV Naloxone is used to reverse opioid induced respiratory depression ,(titrated in small increments 80mcg in adult) . Following naloxone administration patient is observed for Renarcotization If residual muscle paralysis is present – inj sugammadex or additional cholinesterase inhibitor is given 19

20. Circulatory complications Hypotension – usually due to hypovolemia ,left ventricular disfunction ,or excessive arterial vasodilation . Hypovolemia most common cause in PACU can result from inadequate fluid replacement , wound drainage , or hemorrhage . Correction – 250-500ml crystalloid or 100-250 ml colloid bolus In severe hypovolemia vasopressor and inotrope(dopamine or epinephrine )is given 20

21. H ypertension –noxious stimulation due to incisional pain .endotracheal intubation, bladder distension, fluid overload or perioperative discontinuation of antihypertensive medication can lead to HTN Moderate elevations are treated with IV labetalol, enalapril,or nicardipine . Marked HTN in patients require intra-arterial pressure monitoring with IV infusion of nitroprusside NTG , Clevidipine & fenolopam 21

22. Arrhythmias – Respiratory disturbances ,hypoxemia ,hypercarbia, acidosis , residual effect of anesthetic agents ,preexisting cardiac or pulmonary disease predispose to arrhythmias Bradycardia is commonly due to residual effect of cholinesterase inhibitors ,opioids , or beta agonist or fever. 22

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24. Discharge criteria from PACU Before discharge, patients should have been observed for respiratory depression for at least 20–30 min after the last dose of parenteral opioid. Other minimum discharge criteria for patients recovering from general anesthesia usually include the following : 1 . Easy arousability 2 . Full orientation 3 . The ability to maintain and protect the airway 4 . Stable vital signs for at least 15–30 min 5 . The ability to call for help, if necessary 6 . No obvious surgical complications (such as active bleeding ) 7. Postoperative pain and nausea and vomiting must be controlled 8. Normothermia Scoring systems for discharge are widely used 24

25. Scoring systems Standard M odified Aldrete score: Simple sum of numerical values assigned to activity ,respiration ,circulation ,consciousness, and oxygen saturation A score of 9/10 shows readiness for discharge. Post- Anaesthesia discharge scoring system : (PADSS) Modification of the Aldrete score which also includes an assessment of pain , PONV, surgical bleeding in addition to vital signs and activity . A score of 9/10 shows readiness for discharge. 25

26. Criteria for the Determination of Discharge S core for Release from the PACU 26

27. Criteria for Determination of Discharge Score for R elease Home to a Responsible adult 27

28. The majority of patients can meet discharge criteria within 60 min from the time of PACU arrival. Patients to be transferred to other intensive care areas need not meet all requirements. In addition to the above criteria, patients receiving regional anesthesia should also be assessed for regression of both sensory and motor blockade. Documenting regression of a block is important. In some centers, outpatients who meet the above discharge criteria when they come out of the operating room may be “fast-tracked,” bypassing the PACU and proceeding directly to the phase 2 recovery area. In addition to emergence and awakening, recovery from anesthesia following outpatient procedures includes two stages : home readiness (phase 2 recovery) and complete psychomotor recovery. The assessment of home readiness is the responsibility of the qualified anesthesia provider , preferably one who is already familiar with the patient Patients must be provided with written postoperative instructions on how to obtain emergency help and to perform routine follow-up care. 28

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30. Thank you 30