POST ANESTHESIA CARE

UNIT (PACU)
Dr. Dwiana Sulistyanti, SpAN.,Mkes.,KAO

Bagian Anestesiologi & Reanimasi Fakultas

Kedokteran Unmul/RS. AW Sjahranie
Samarinda
 Design
should be located near the operating rooms
radiographic, laboratory, and other intensive care
facilities on the same floor
An open ward design facilitates observation of all
patients simultaneously
At least one enclosed patient space is desirable for
patients needing isolation for infection control
A ratio of 1.5 PACU beds per operating room is
customary
Each patient space should be well lighted and large
enough to allow easy access to patients
Multiple electrical outlets and at least one outlet for
oxygen, air, and suction should be present at each
space.
 Equipment
Most PACU incidents leading to serious morbidity or mortality
are related to inadequate monitoring

Pulse oximetry (SpO2),

electrocardiogram (ECG), and monitors for each space are
automated noninvasive desirable but not mandatory
blood pressure (NIBP)

A forced-air warming device, heating lamps, and warming/cooling

blanket
Should have its own supplies of basic and emergency equipment
 Equipment
A defibrillation device, an emergency cart with
drugs,and infusion pumps should be present.
Tracheostomy, chest tube, and vascular
cutdown trays are also important.
Respiratory therapy equipment for aerosol
bronchodilator treatments, continuous positive
airway pressure (CPAP), and ventilators should
be in close proximity to the recovery room.
A bronchoscope for the PACU is desirable but
not mandatory.
 Staffing
Should be staffed only by nurses
specifically trained in the care of patients
emerging from anesthesia
Should be under the medical direction of
an anesthesiologist.
A physician assigned full-time to the PACU is
desirable in busy centers but is not mandatory in
smaller facilitie
a ratio of one recovery nurse for two
patients is generally satisfactory
 Admission to the PACU

Anesthesiologist should provide an admission

Report to the PACU nurse and
supervise care of patient until vital sign are obtained
 Admission to the PACU
Admission report to the PACU nurses

1. Preoperative history 2. Intraoperative factors

Chronic medications Surgical procedure
Preexisting disease Type of anesthetic and drug doses
Drug allergies Muscle relaxant and reversal status
Premedication Intravenous fluid
Estimated blood loss
3. Postperative history Urine output
Pain management Unexpected surgical or anesthetic events
Acceptable vital sign range, blood Intraoperative vital signs and laboratory
loss, and urine output findings
Anticipated cardiopulmonary Nonanesthetic drugs (antibiotics, diuretics,
problems vasopressors)
Diagnostic tests
Location of responsible physician
 Routine Recovery
General Anesthesia
Airway patency, vital signs, and oxygenation should
be checked immediately on arrival
All patients should receive 3040% oxygen during
emergence
BP, PR, and RR every 5 min for 15 min or until
stable, and every 15 min thereafter
Pulse oximetry should be monitored continuously
Neuromuscular function should be assessed clinically
At least one temperature measurement should also
be obtained
 Routine Recovery
Regional Anesthesia
supplemental oxygen Patients who are heavily
sedated or hemodynamically unstable following
regional anesthesia
Sensory and motor levels should be periodically
recorded
Blood pressure should be closely monitored following
spinal and epidural anesthesia.
Bladder catheterization may be necessary in patients
who have had spinal or epidural anesthesia for longer
than 4 h.
 Routine Recovery
Pain Control
Agitation
Nausea & Vomiting
Shivering & Hypothermia
Discharge Criteria
 Table. Postanesthetic Aldrete Recovery Score.1,2

Original Criteria Modified Criteria Point Value

Color Oxygenation

Pink SpO2 > 92% on room air 2

Pale or dusky SpO2 > 90% on oxygen 1

Cyanotic SpO2 < 90% on oxygen 0

Respiration

Can breathe deeply and cough Breathes deeply and coughs freely 2

Shallow but adequate exchange Dyspneic, shallow or limited breathing 1

Apnea or obstruction Apnea 0

Circulation

Blood pressure within 20% of normal Blood pressure 20 mm Hg of normal 2

Blood pressure within 2050% of normal Blood pressure 2050 mm Hg of normal 1

Blood pressure deviating > 50% from normal Blood pressure more than 50 mm Hg of normal 0

Consciousness

Awake, alert, and oriented Fully awake 2

Arousable but readily drifts back to sleep Arousable on calling 1

No response Not responsive 0

Activity

Moves all extremities Same 2

Moves two extremities Same 1

No movement Same 0

1Based on Aldrete JA, Kronlik D: A postanesthetic recovery score. Anesth Analg 1970;49:924 and Aldrete JA: The
post-anesthesia recovery score revisited. J Clin Anesth 1995;7:89.
2Ideally, the patient should be discharged when the total score is 10 but a minimum of 9 is required.
 Table. Postanesthesia Discharge Scoring System (PADS).

Criteria Points
Vital signs
Within 20% of preoperative baseline 2
Within 2040% of preoperative baseline 1
> 40% of preoperative baseline 0
Activity level
Steady gait, no dizziness, at preoperative level 2
Requires assistance 1
Unable to ambulate 0
Nausea and vomiting
Minimal, treated with oral medication 2
Moderate, treated with parenteral medication 1
Continues after repeated medication 0
Pain: minimal or none, acceptable to patient, controlled with oral medication
Yes 2
No 1
Surgical bleeding
Minimal: no dressing change required 2
Moderate: up to two dressing changes 1
Severe: three or more dressing changes 0

1Based on Marshall SI, Chung F: Discharge criteria and complications after ambulatory surgery. Anesth Analg 1999;88:508.
2Score 9 is required for discharge
COMPLICATIONS
 Cardiovascular Complications
Postoperative hypotension
A 20 to 30% decrease in BP from baseline
Differential diagnosis
Arterial hypoksemia
Hypovolemia
Spurious (cuff to wide, transducer not calibrated)
Pulmonary edema (excess fluid)
Myocardial ischemia
Cardiac dysrhythmias
SVR (regional blocks, drugs)
Pneumothorax
Cardiac tamponade.
 Cardiovascular Complications
Postoperative hypotension
Treatment is determined by the mechanism
responsible for hypotension.
Oxygenation
Crystalloid solution (most appropriate): 300-500 mL iv over
15 minutes.
Transient improvement may indicate continual surgical bleeding
Absence of any improvement may reflect cardiac dysfunction
Vasopressors are temporizing measure to restore perfusion
pressure while the underlying cause for hypotension is
corrected
 Cardiovascular Complications
Postoperative hypertension
A 20-30% increase in BP from baseline
Differential diagnosis
Arterial hypoxemia
Spurious (cuff too narrow, transducer not
calibrated)
Preexisting essential hypertension
Enhanced sympathetic nervous system activity
Excess fluid administration
hypothermia
 Cardiovascular Complications
Postoperative hypertension
Treatment is determined by the mechanism
responsible for hypertension
Adequacy of oxygenation
Antihypertensive medications
 Cardiovascular Complications
Cardiac dysrhytmias
Differential diagnosis
Asymptomatic ECG abnormalities
Bradycardia (increased PNS activity; heart block)
Tachycardia (increased SNS, paroxysmal atrial
tachycardia)
Premature contraction (atrial usually benign;
ventricular may be life-threatening.
 Cardiovascular Complications
Cardiac dysrhytmias
Treatment is determined by the significance of
the cardiac dysrhytmias
Eliminate excessive PNS activity (atropine,
ephedrine)
Eliminate excessive SNS activity (analgesics, beta
antagonists)
Decreased ventricular irritability (lidocaine)
Artificial pace maker insertion vs administration of
isoproterenol
 Respiratory Complications
Airway Obstruction
most commonly due to the tongue falling back
against the posterior pharynx
Other causes include laryngospasm; glottic
edema; secretions, vomitus, or blood in the
airway; or external pressure on the trachea
combined jaw-thrust and head-tilt maneuver
pulls the tongue forward and opens the airway
Insertion of an oral or nasal airway (nasal may
be better tolerated than oral)
 Respiratory Complications
Hypoventilation
Differential diagnosis;
Inadequate ventilatory drive (residual effects of anesthetics; lack of sensory
stimulation)
Ventilatory mechanics
Increased airway resistance
Decreased compliance (obesity, fluid overload)
Residual neuromuscular blockade
Increased dead space (pumonary embolus)
Increased carbon dioxide production (hyperthermia, hyperalimentation)

TREATMENT;
should generally be directed at the underlying cause
Obtundation, circulatory depression, and severe acidosis (arterial blood pH <
7.15) are indications for endotracheal intubation
If naloxone is used to increase respiration, titration with small increments
(0.04 mg in adults)
Antagonism of opioid-induced depression with naloxone is a two-edged
sword
 Respiratory Complications
Hypoxemia
Differential diagnosis
Distribution of ventilation ( mismatch of ventilation to perfusion)
Distribution of perfusion (mismatch of perfusion to ventilation)
Inadequate alveolar oxygen partial pressure
Decreased mixed venous oxygen partial pressure.

Treatment
Oxygen therapy with or without positive airway pressure
Oxygen concentration must be closely controlled in patients with chronic
CO2 retention
100% oxygen via a nonrebreathing mask or an endotracheal tube for
patients with severe or persistent hypoxemia.
Additional treatment should be directed at the underlying cause
Persistent hypoxemia in spite of 50% oxygen generally is an indication for
positive end-expiratory pressure (PEEP) or CPAP.
Bronchoscopy is often useful in reexpanding lobar atelectasis caused by
bronchial plugs or particulate aspiration. cause