Post anesthesia care Unit (PACU).pptx

principle of post anesthesia care

1. Post anesthesia care Unit (PACU) Amanuel Sisay (MSc) 1

2. Course objectives (1/4) Explain techniques of postoperative patient’s transportation. Recognize methods of handover for postoperative patients. Recognize recovery and other positions in the PACU. Describe the required equipment’s and monitoring in the PACU. Explore patient follow up strategies in the PACU. Analyze monitoring parameters in the PACU. Identify common postoperative complications in PACU. Discussed adverse outcomes of untreated postoperative pain Assess severity of acute pain. 2

3. Course objectives (2/4) Explore different modalities of postoperative pain management. Describe adverse effects of different analgesics. Recognize the impact of PONV Describe the factors that predispose to PONV Describes prevention, treatment the basic pharmacology of anti-emetic drugs . Identify possible causes of hypoxia and hypoventilation Describes how to evaluate neuro-muscular blocker with the nerve stimulator. Identify management of laryngospasm and other complications of extubation List indications of oxygen therapy Describe techniques of oxygen therapy 3

4. Course objectives (3/4) Describes the causes and management of postoperative atelectasis, tachycardia, bradycardia, arrhythmias, bleeding, hypotension and hypertension. Describe mechanisms and management of hypothermia. Describes the possible causes and management of postoperative confusion and cognitive deterioration. Identify conditions that need higher level of postoperative care. Explain discharge criteria (Modified Aldrete Criteria )from PACU (in-hospital or home) Identify organizational and structural requirements of the PACU Identify common critical incidents (Cardiorespiratory arrest) in the PACU and early warning assessment methods Arrange the organization and requirements of safe PACU Interpret monitoring parameters and intervene accordingly. Evaluates neuromuscular blockade using a nerve stimulator. 4

5. Course objectives (4/4) Administer oxygen with different techniques (nasal prongs, facemasks…) Assess postoperative pain. Prescribes appropriate postoperative analgesia. Prescribes appropriate postoperative fluid regimes Manage amenable bleeding and provide resuscitation. Prevent, assess and manage hypothermia in the PACU 5

6. Session 1: (Start from tomorrow) Organization, staffing and safety of PACU Admission and discharge criteria to PACU Transportation handover and positioning Equipment and monitoring required in the PACU Physiology, assessment, management of postoperative acute pain 6

7. Session 2: Mechanisms, impacts, factors, prevention and management of PONV Causes of hypoxia and hypoventilation, oxygen therapy Identification prevention and management of other common postoperative complications (atelectasis, tachycardia, bradycardia, arrhythmias, bleeding, hypotension, hypertension, hypothermia, confusion and cognitive deterioration ) 7

8. Session 3: Assessment and management of Post anesthesia cognition and confusion Assessment for discharge from PACU (in-hospital and home) Reassuring and helping patients in CRC manner and develop interdepartmental communication and collaboration 8

9. Methods of Assessment (1/1) Formative Drills, essay exams, quizzes, and practical test (direct observation of skills) Structured feedback report Logbook Portfolio DOP, PCE, CBD And other assessment methods Summative Progressive/ Continuous assessment: (10%) DOP, PCE, CBD: (15%) Written exam (50%) Objectively Structured Clinical Examination (OSCE): (15%) 9

10. Reference Books Paul G Barash: Handbook of Clinical Anesthesia (6th edition). Lippincott Williams & Wilkins publications, Inc., 2009. Paul G Barash: Clinical Anesthesia (7th edition). Lippincott Williams &Wilkins publications, Inc., 2014. Ronald D. Miller: Millers Anesthesia (8th edition). Churchill Livingstone publication, An Imprint of Elsevier, 2015. G. Edward Morgan: Clinical Anesthesiology (5th edition). McGraw-Hill Companies, Inc., 2006 Ronald D. Miller: Basics of Anesthesia (7th edition). Saunders, an imprint of Elsevier Inc. 2011. Fleisher: Anesthesia and Uncommon Diseases, (5th edition). Elsevier Saunders Inc., 2005 James C. Duke: Duke’s Anesthesia Secretes (5th edition). Saunders, an imprint of Elsevier Inc. 2016. 10

11. Postanesthesia Recovery Patients recovering from an anesthetic has circumstances that require individualized problem-oriented approach. Postanesthesia recovery must continue to adapt to meet the needs of the changing - - perioperative landscape - advances in technology - changing surgical techniques - to respond to improved evidence-based research 11

12. Levels of Postoperative/ Postanesthesia Care anesthesia services expand to cover a variety of patient types everincreasing areas outside the operating room selecting the correct type of recovery is essential 12

13. many differing anesthesia areas ranging from inpatient surgery, ambulatory surgery, to off-site procedures the level of postoperative care that a patient requires is determined by: the degree of underlying illness, comorbidities, and the duration the type of anesthesia and surgery. 13

14. Phase I recovery would be reserved for more intense recovery and would require more one-on-one care for staff. Phase II recovery should be less intensive and is appropriate for patients after less invasive procedures requiring less attention from nursing while recovering. If separation of different phases of care is not possible, then providing the appropriate level of monitoring and coverage to the degree of postoperative impairment achieves similar results in a single PACU area. 14

15. Postanesthetic Triage Triage should be based on clinical condition, length/type of procedure and anesthetic, the potential for complications that require intervention. Arbitrary criteria should not be used for determining the level of recovery care. age, ASA classification, ambulatory versus inpatient versus off-site procedure status type of insurance 15

16. intensive procedures and patients with greater acuity, bypassing the PACU direct admission to intensive care units can reduce demands on the PACU reduce errors with decreased number of hand offs 16

17. Safety in the Postanesthesia Care Unit Every PACU should have medical oversight in the form of a medical director Medical director must ensure the PACU environment is as safe as possible for both patients and staff Beyond usual safety policies, maintain staffing and training to ensure that an appropriate coverage and skill mix is available to deal with unforeseen crises. Incidence of adverse events in the PACU correlates with nursing workload and staff availability. Ideally, all staff should have PACU certification, and staffing ratios should never fall below acceptable standards 17

18. The staff is obligated to optimize each patient’s privacy and dignity to minimize the psychological impact of unpleasant or frightening events. Observance of procedures for handwashing, sterility, and infection control should be strictly enforced. Access to the PACU should be strictly controlled. Increasing acceptance of reuniting patients with family/friends, safety and privacy issues need to be continually addressed. 18

19. The PACU environment must also be safe for professionals. Air handling should guarantee that personnel are not exposed to unacceptable levels of trace anesthetic gases (although trace gas monitoring is not necessary) Staff members receive appropriate vaccinations, including those for hepatitis B, flu, and others required by their institution. Personal protective equipment (PPE) such as gloves and eye protection Worn to protect both the patient and provider Having masks, gowns, and appropriate particulate respiratory equipment easily accessible is needed for particular cases. 19

20. Routine Post- Anaesthesia Care Criteria for shifting from OR- --to--- PACU Haemo dynamic stability Clinical evaluation and complete recovery from NM blockade Maintenance of Oxygen Saturation Normothermia < C 9 ATL

21. - - ,a.j cow., Transport of client from OR to RR r avo id ex posure r avoi d r oug h ha ndling r avo id h urried mo ve me nt and r apid cha n ges in p osi ti on.

22. Admission Report Preoperative history Intra- operative factors: Procedure Type of anesthesia Estimated Blood Loss (EBL) . Urine output ·You seem quieter tonight. Did they give yousometh i ng to help yourelax? " Assessment and report of current status Post-operative instructions

23. PACU Vital signs are recorded as often as necessary but at least every 15 minutes while the patient is in the unit.

24. PACU Oxygenation pulse ox i metry Ventilation Resp Rate , a i rway patency , capnography Circulation BP , HR , ECG Level of consciousness

25. Pat i ent may fee l the follo w ing up to 2 4 h ours Sor e t hroa t Ach i ng muscles General mala i se Shiver i ng - not uncommon Warm cotton b l anke t s applied as necessary Warm ai r bla n ket may be utilized M e dicatio n is u sed f or ex t r e m e s h ive r ing 2')

26. Discharge criteria from PACU Neither an arbitrary time limit nor a discharge score can be used to define a medically appropriate length stay in the PACU accurately All patients must be evaluated by anesthesiologist/trained staff prior to discharge from PACU Criteria for discharge developed by the Anesthesia department Criteria depends on where the patient is sent - ward, ICU, home

27. Discharge criteria from PACU Easy arousability Full orientation : Ability to maintain & protect airway •! Stable vital signs for at least 15 - 30 minutes The ability to call for help if necessary No obvious surgical complication (active bleeding)

28. Discharge From the PACU Standard Aldrete Score: ::i Simple sum of numerical values assigned to activity, respiration , circulation , consciousness , and oxygen saturation. A score of 9 out of 1O shows readiness for discharge. Post-anesthesia Discharge Scoring System: Modification of the Aldrete score which a l so includes an assessment of pain , N/V, and su r gical bleeding , in addition to vital signs and activity. Also , a score of 9 or 10 shows readiness for discharge.

29. ALDRETE SCORE Post- Anesthesia Score A total discharge score of 8- 10 is necessary Post- Anesthesia Score PRE- ANESTHESIA VITAL SIGNS/SOURCE TIME ADM 1s- 30- 45" 1' 2' 3' • DISCHARGE SYSTOLIC BP 20% OF PRE- ANESTHETIC LEVEL CIRCULATION 20- 50% > so 2 1 ) CONCIOUSNES FULLY AWAKE AROUSABLE ONCALLING 2 1 s NOT RESPONDING WARM, DRY SKIN W I PREPROCEDURAL COLORING 2 COLOR PALE, DUSKY , BLOTCHY, JAUNDICED, OTHER CYANOTIC 1 ABLE TO DEEP BREATHE & COUGH FREELY RESPIRATION APKEIC 2 DYSPNEA OR LIMITED BREATHING 1 CTJVITY ABLE TO MOVE 4 EXTREMITIES 2 ABLE TO MOVE 2 EXTREMITIES 1 ABLE TO MOVE O EXTREMITIES COM NiJi 3 , 41,.;a JIM TOTAL so

30. Activity Respiration Circu l ation Consc i ousn e ss Oxygen Saturat i on 2: Movesall ext r emit i es 2 : Brealhs deeply and coughs 2 : BP + 20 mm of pre - anesthetic 2 : Fu ll y awake 2 : Spo 2 > 92% on room air volun t arily/ on command freely . l evel 1: Moves2 ext r emities 1: Dyspneic , sha ll ow o r lim ited b r eathing 1 : BP+ 20 - 50 m m pre - anesthetic l eve l 1 : A r ousab l e on calling 1 :supp l emental 02 require<! to maintain Spo2 >90% 0: Unable lo move ext r emities 0: Apne i c : BP + 50 m m of preanesthe i c level 0: Not r esponding O: Spo2 <92 % with 02 supp l ementation Aldrete Score

31. Interpretation of Aldrete's score Lowest score = - 2 Score for patient to be shifted to next level of care= 9 o Since some patients on arrival to PACU will meet the score of 8, it is very illogical to fix a number for shifting the patient a Ideally it should be decision of the Anesthesiologist regarding the shifting from the PACU to next level of care taking into account the anesthetic plan & the drugs given intra- operatively as well as in PACU 2/.J/2mS 3:48:01 PM 52

32. Vital Signs (BP and Pul se ) A c tiv i ty Nau s ea a nd Vom i ting Pain Surgi c al Bleeding 2: Within 20% ef preoperative 2 : Steady ga i t , no dizziness 2: M i nimal: t reat with PO meds 2 : Ac:ceptable controlper the 2 : Min i mal : no dress i ng basel i ne patient ; c o ntro ll ed wi t h changes requ i red POmeds 1: 20-40 % of p r eopera ti ve 1: Requ i res assistance 1 : Moderate : t r eat with I M 1 : Not acceptable to the 1 : Moderate : up to 2 dressing baseline medications patient ; not changes contro ll ed with PO med i cations 0: >40 % of preoperative baseline 0: Unable to ambulate 0: Continues: repeated treatment : Severe : more than 3 dressing changes ( @ ATLAS Post-anesthesia Discharge Scoring System (PADSS) S3

33. Discharge from the Post Operative Unit A patient remains in the post op unit, until the pat ien t has fully recovered from -...._ - _::::. .:::.. anesthesia. Following measures are used to determine the patient ready for discharge from post operative unit:­ Stable vital signs Orientation to Person, Place Time or events Adequate oxygen saturation level. Urine out put at least 30ml/hour Minimal pain . Adequate respiratory function . Aldrete score more than ' 9 ' "You' ll be glod to know your daughter's surgery went fine ond she ' s owoke Clnd textlng." 2/.J/21l15 3:48:01 PM

34. Teaching, Patient Self Care ( ( 9 ATLA Expected out comes Immediate post operative changes Written instructions like Wound care Activity+dietary recommendation Medications Follow up 2 / 4 / 2015 3 : 48:01 PM ss