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PACU

(Post Anesthesia Care Unit)

Pendahuluan
Salah satu perubahan paling penting
dalam praktek bedah : rawat inap
rawat jalan.
USA : bedah rawat jalan 70% dari
seluruh operasi terencana (elektif).
Inggris: 34% pada tahun 1989 menjadi
49% pada tahun 2001 , 2002.
Keuntungan bedah rawat jalan: biaya
lebih murah, menguntungkan untuk
pasien dan keluarganya.
McGrath B, Chung F. Anesth Clin of North
America, June 2003; 21(2)

Definisi Pemulihan
Pemulihan segera : saat pasien
bangun dari anestesi.
Pemulihan Intermediet: bila
pasien mencapai kriteria untuk
dipulangkan
Pemulihan Jangka Panjang: bila
pasien kembali ke keadaan fisiologis
seperti sebelum di operasi.
McGrath B, Chung F. Anesth Clin of North America, June 2003;
21(2)

Phase I (Early) recovery,


PACU, Modified Aldrete Score

Phase II (Intermediate) recovery


step down unit, PADSS

Phase III (late) recovery, home

Postanesthesia Recovery Score


(Modified Aldrete Score)
Color criteria, change to Oxygen
Saturation
Oxygen Saturation :
2= SpO2 > 92% on room air
1= Supplemental O2 req to maintain
SpO2>90%
0= SpO2 <92% with O2
supplementation
10= total score; 9 for PACU
discharge/bypass

Fast tracking
SAFE
Advent of rapid and short acting drugs for
induction and maintenance of anesthesia
(Propofol, Sevoflurane, Desflurane,
remifentanyl).
Patient can achieve Aldrete score 9 or 10
upon arriving in the PACU.
Fast tracking refers to ability to transfer
directly from OR to Phase II recovery area.

Discharge
A successful ambulatory surgical program
depends on the appropriate and time
discharge of patient after anesthesia.
Using PADSS : base on vital sign
(BP,HR,RR, temp), ambulation,
nausea/vomiting, pain, surgical bleeding.
Recovery Phase I : Modified Aldrete Score.
Phase II Recovery: PADSS

Can patients be safely discharged


without tolerating oral fluid?
Higher incidence of nausea and
discharge delay among mandatory
drinker.
Oral fluid withheld for 4-6 hours
postop, incidence vomiting less than
the group that drank.
PGPAC: drinking of fluid should not be
part of a discharge protocol

Is voiding necessary before


discharge?
Traditionally voiding as a prerequisite to
discharge.
Postoperative urinary retention caused by
surgical manipulation, bladder distention,
pain, anxiety, residual effect of
spinal/epidural.
PGPAC: should not be part of a discharge
protocol.
Seek medical help if unable to void within
6-8 hours of discharge.

AFTER
GUIDE
LINES

Discharge of patients after


Spinal anesthesia
Same discharge criteria as GA.
SA widely used in the ambulatory setting.
Lower incidence of PONV, drowsiness, post
operative pain than GA.
TNS with lidocaine
Discharge : RA more faster than GA, GA
more faster than RA, no difference
discharge time.

Factors delaying discharge


Increasing age: a 10 year difference in
age being associated with a 2% change
in length of stay.
Preoperative predictors of delayed of
discharge: ENT, strabismus surgery,
CHF.
Intraoperative factors: GA, long
duration of surgery, present
intraoperative cardiac event
Postoperative: pain, PONV, logistic
factor.

Common PACU problems and


treatment :
Pain
PONV
Postoperative pain and PONV are 2
factors that commonly prolong
postoperative stay after ambulatory
surgery.

Postoperative pain
Main criteria performing ambulatory
surgery is minimal postoperative pain,
and can be controlled with oral
analgesia.
Pain is still a common reason for delay
in discharge, for contact with the family
doctor, for unanticipated hospital
admissions.
Important to understand the pattern of
pain and define predictive factor for
severe pain (orthopedic, duration of
surgery : >90 minutes 10% severe pain,

Postoperative analgesics in the


ASU
Drug

Dose

Route

Fentanyl
Meperidine
Morphine
Acetaminophe
n
Codeine
Ketorolac

1,0-2,0 ug/kg
0,5-1 mg/kg
0,05-1,0 mg/kg
60 mg/year or 25-40
mg/kg
0,5-1 mg/kg
30-60 mg (0,5-1
mg/kg)

Iv
Im
Iv/im
Po/pr
Po
Im/iv

Twersky RS. ASA Annual Meeting, 2002

PONV
Remain problem after ambulatory surgery.
Avoid using N2O, Prostigmine.
20-30% after GA, 35% of patients after
discharge home.
Antiemetic with droperidol 0,625-1,25 mg
iv, droperidol 0,625 + metoclopramide 10
mg iv, ondansetron 4-8 mg iv,
dexamethasone 8 mg iv.
Twersky RS. ASA Annual Meeting, 2002

Common causes of Nausea and


vomiting in outpatients (1)
Predisposing factors: female, motion
sickness, morbid obesity, early
pregnancy.
Increasing gastric volume: excessive
anxiety.
Premedicants: narcotic analgesics

Common causes of Nausea and


vomiting in outpatients (2)
Anesthetic agents : inhaled gas,
intravenous drugs.
Surgical procedures: laparoscopy,
strabismus correction, insertion of PE
tube, orchidopexy.
Postoperative factors: hypotension,
pain.

Incidence of PONV cause by


anesthetics agent (%)
SEVO

ISO

HAL

DES

PROP

6-74
(2-20)

33-69
(8-33)

6-20
(8-13)

20-38

12-20
(0-7)

Other factors delaying discharge


Sore throat, headache, dizziness,
drowsiness.
Thirst, nausea, dizziness, drowsiness
avoid by perioperative hydration
with 20 ml/kg.
Overall post discharge symptoms:
45% for pain, 17% for nausea, 8% for
vomiting.

Patient education
Patient have a responsible individual
to accompany at home after
discharge (reduce adverse
outcomes, increase patient comfort
and satisfaction).
Provided written instruction (diet,
medications, activities, phone
number).
Not consume alcohol, drive vehicles,
make important decisions for 24
hours.

Patients education (2)


Should not drive for 24 hour after an
anesthetic less than 1 hour, if the
duration is 2 hour or more, should
abstain from driving for 24 hour
(Anesthesia with thiopentone,
halothane).
New drugs (Sevoflurane, Desflurane,
propofol, remifentanyl) : 3 hours

Treatment recommendation

Prophylaxis and treatment of pain & PONV.


Supplemental oxygen.
Fluid administration and management.
Normalizing patient temperature.
Pharmacological agent for the reduction of
shivering.
Antagonism of the effect of sedatives,
analgesics, and neuromuscular block.

Factors that determine


satisfaction
Friendliness of the OR staff.
Surgeons discussion of the operative
finding.
Management of postoperative pain.
Starting their I.v smoothly.
Avoidance of delay.
Tarazi EM, Philips BK. Anesth 1995;83

Summary
Formulating an ambulatory
anesthesia plan that balances drugs
effectiveness, side effect profile,
patients preference, and associated
reduction of total cost.
Patient arrive for ambulatory surgery
anesthesia with the mistaken
perception that the experience will
be no more difficult than walk in the
park

THANK YOU VERY


MUCH

References
Practice Guidelines for Postanesthetic
Care. Anesthesiology, March 2002;96(3).
Twersky R. Recovery and Discharge of the
Ambulatory Anesthesia Patient. ASA
Annual Meeting, Oct 2002.
McGrath B, Chung F. Postoperative
recovery and discharge. Anesth Clin of
North America, June 2003; 21(2)