PACU: (Post Anesthesia Care Unit)

Q1. A) What are the causes of delayed recovery from GA?

B) How will you manage such a case?

Ans A) Patient fails to regain consciousness 30-60min after surgery under general
anesthesia.

CAUSES:

1. Residual anesthesia effect (sedative, analgesic, NMBAs)

2. Drug overdose (opioids, NMBAs, sedatives, inhalation agents)
3. Hypothermia
4. Metabolic disturbances like -Hypercarbia/Hypocapnia (hypocarbia)
5. Perioperative stroke. -Hypoxemia
-Hypercalcemia
-Hyper/hypoglycemia
-Mg
-Na

Ans B)

MANAGEMENT: Rule out and treat the cause

Opioid overdose Naloxone 0.04mg (increments)

Benzodiazepine overdose Flumazenil 0.2 mg (increments)
NMBAs effect Use nerve stimulator and repeat Neostigmine/ Pyrolate if
needed
Hypothermia Use forced warm blankets
ambient temperature of PACU
Warm I/V fluids
Keep patient anesthetized until temp normalizes.
Perioperative stroke neurophysician consultation for CT
Metabolic disturbances: Send investigation and ABGs
&correct them accordingly

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Q2) what are the causes and treatment of post operative HTN?

CAUSES:

Pre-existing
1. Undiagnosed HTN or poorly controlled
2. PIH
3. Withdrawal of anti-hypertensive.
4. ICP

Sympathetic tone
1. Inadequate analgesia
2. Hypoxia
3. Hypercapnia
4. Airway instrumentation (nasal and Guedel airway, frequent suctioning)
5. Bladder distension (Catheter Obstruction)

Drug over dosage:

1. Epinephrine
2. Ephedrine/ Phenylephrine
3. Ketamine
4. Ergotamine.

Others:
1. Fluid over dosage.
2. Pheochromocytoma
3. Malignant Hyperthermia
4. Thyroid storm
5. Metabolic acidosis
6. Measurement error (small cuff)

TREATMENT:
OBJECTIVE: Control blood pressure to prevent end organ damage (Brain, heart,
kidney)
1. Mild HTN do not require any treatment (only observes)
2. BP >25 % form baseline will be consider to teat
3. Along with BP associated adverse effects like myocardial ischemia, heart
failure or bleeding should be treated.
4. Mild to moderate HTN should be treated with I.V. -Blockers like labetalol,
esmolol or propranolol. If asthmatic then Ca+ blocker
5. Patient with limited cardiac reserves needs invasive monitoring, treat them
with I.V. infusion of GTN, SNP, nicardipine or fenoldopam
6. Control pain via analgesia.
7. Catheterize if bladder is distended or examine the existing catheter
8. O2 via face mask.
9. Send investigation e.g. cardiac enzymes, UCEs
10.Monitor ECG and pulse oximeter
11.Anxiolytics.

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MEDICAL ILLNESS PREDISPOSE PTS TO DELAYED RECOVERY OR PROLONG PARALYSIS

1. Chronic hypertension brain tolerance to episodes of hypotension

2. Diabetes prone to hypoglycemia and hyperosmotic, nonketotic coma
3. Live dx drug metabolism and biliary excretion
4. Hepatic encephalopathy alters consciousness
5. Kidney dx excretion of drugs.
6. Uremia also affects consciousness
7. Prior CVA or symptomatic carotid bruit risk of CVA
8. Sever hypothyroidism.

POSTOPETATIVE PROBLEMS:

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Q 3) Enumerate the problems that can occur in immediate post operative period.
Briefly give the management.

Ans.) Problems in immediate postoperative period:

1. Delayed recovery 8. HTN

2. Post operative pain 9. Thyroid storm
3. PONV 10.Hypotension
4. Hypothermia/ Shivering 11.Hypoxemia
5. Agitation 12.Hypovolaemia
6. Airway obstruction 13.Fever.
7. Hypoventilation /Hypercarbia.

MANAGEMENT:

1-DELAYED EMERGENCE:
1. Rule out any drug overdose and treat accordingly.
2. Correct hypothermia
3. Correct electrolytes
4. Correct acidosis
5. Neuro Physician consultation if stroke is suspected

2-POST OP PAIN:
Pre-operative NSAIDS/acetaminophen
Intra-operative local infiltration, nerve blockade or caudal, epidural infusion if
catheter left in place

3-PONV:
1. Metoclopramide 0.15 mg/kg.
2. Ondansetron 4mg
3. Dexamethasone 4-10mg
4. Adequate hydration.
5. Intraoperative Propofol infusion

4-AGITATION: Midazolam or Physostigmine /haloperidol

5-HYPOTHERMIA /SHIVERING:
1. Forced warm blankets.
2. Ambient temperature of PACU
3. Warm I/V fluids
4. Oxygen via face mask and meperidine 10-50mg for shivering

6-AIRWAY OBSTRUCTION:
1. Supplemental oxygen
2. Jaw thrust
3. Head tilt
4. Chin lift

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 5. Oral/ Nasal airway
6. I/V steroids for glottis edema (children)

7-HYPOVENTILATION /HYPERCARBIA: Identify the cause.

1. Good analgesia
2. Reversal of residual NMBA effect.
3. Opioid antidote Naloxone alternatively dexamethasone
4. Benzodiazepine antidote flumazenil
5. Control ventilation if circulatory depression or sever acidosis PH <7.15

8-HTN:
1. Good analgesia 4. Direct acting vasodilators e.g. GTH,
SNP
2. -Blockers like labetalol, esmolol 5. 2 agonists.
3. Ca+ Blockers like verapamil if asthmatic
methyldopa (Rx)
9-THYROID STORM: (Medical emergency)
1. Dexamethasone 6. I/V fluids
2. Propylthiouracil 7. Vasopressor
3. Na/K iodide. 8. Digoxin (a fib)
4. -blockers 9. Post operative ICU
5. Surface cooling 10. Admission

10-HYPOTENSION:
1. Adequate O2
2. Vasopressors 6. Head up position
3. Correct acidosis 7. 12 lead ECG ischemia/infarction
4. If surgical bleeding resuscitate with fluids
5. If resistant then use inotropes

11-HYPOXEMIA:
1. Assess ECG 4. Rule out airway obstruction
2. Oxygen via face mask. 5. Correct hypothermia

12-HYPOVOLEMIA:
-Resuscitate with fluids, -Monitor urine out put

13 FEVER: Treat the casus

POSTOP APNEA:

Q4. What is the D/D of post-operative apnea?

How will you treat it?

D/D OF POST OF APNEA:

1. Succinyl apnea
2. Previous H/O OSA

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 3. Opioid overdose/ sedatives overdosage
4. Inadequate reversal of NMBA
5. Residual effects of inhalational agents.
6. Hypocarbia or Hypocapnia
7. Hyperoxemia in COPD pts. especially smokers
8. Morbid obesity
9. Airway obstruction.
10.Unsecure airway of semi conscious pts in PACU
11.Retro-bulbar block.

TREATMENT:
1. Jaw thrust, head tilt, chin lift and supplemental oxygen
2. Reversal of opioids/sedatives overdosage.
3. Reversal of NMBAs after checking with nerve stimulator BiPAP: Bilevel Positive Airway Pressure,
CPAP: Continuous Positive Airway Pressure.
4. BiPAP/ CPAP in morbid obese K/C of OSA pt. (Obstructive Sleep Apnoea)
IPPV: Intermittent Positive Pressure
5. Clear the airway (secretions, Blood) Ventilation
6. Use of oral/nasal airway in semiconscious pts
7. Rebreathing face masks for COPD Pt.
8. Venturi device for COPD patients
9. Support the airway with IPPV if required.
10.Succinylcholine apnea FFPs and electively ventilate till diagnosis is
established or breathing regained

POSTOPERATIVE PAIN MANAGEMENT:

Q.5) Describe post operative pain management of a young lady?

Ans.)
PREOP:
Acetaminophen post operative opioid requirements
NSAIDs

INTRAOP:
Local anesthetic infiltration
Nerve blockades (ilioinguinal/ caudal/ Epidural)

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 I.V. Opioids (fentanyl, nalbuphine, morphine)
I.M. NSAIDs (Diclofenac)

POSTOP:
Mild to moderate:

Oral acetaminophen + Codeine, oxycodone, hydrocodone

Opioids (Nalbuphine 5-10mg) or (Tramadol)
NSAID (Ketorolac 30mg

Moderate to Severe:

Parenteral/ Inrtraspinal opioids (fentanyl, morphine)

Regional anesthesia (epidural)
Specific nerve blocks e.g. (caudal, femoral, intercostal, interscalene)
PCA (for inpatients) when fully awake
Meperidine, hydromorphane, morphine

HYPOXEMIA MANAGEMENT:

Q6.) A 29 year old female brought to PACU after an uneventful lap-choley under G/A.
In recovery her SpO2 is 88%

a) Discus the causes of hypoxemia in recovery?

b) How will you manage it?

Ans. a)
CASUES:

Physiological Pathological
1. Low FiO2 1. Airway obstruction (bronchospasm)
2. Hypoventilation (PaCO2) 2. Atelectasis
3. V/Q mismatch. 3. Bronchial intubation (Rt.)

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4. Intrapulmonary shunting. 4. Aspiration.
5. Pulmonary edema.
6. Pneumothorax/ Pulmonary embolism.

Ans b)
MANAGEMENT:
1. Oxygen therapy with or without positive airway pressure
2. Oxygen concentration must be controlled in COPD Pts to prevent acute
respiratory failure.
3. Until the cause is established pt should receive 100% O 2 via non-rebreathing
mask.
4. Persistent hypoxemia despite 50% O2 is indicative of PEEP or CPAP.
5. Bronchospasm should be treated with aerosolized bronchodilators/ IV
aminophylline.
6. Chest tube should be inserted for any symptomatic pneumothorax
7. Diuretics should be given for any fluid overload.
8. Bronchoscopy is useful in re-expanding lobar atelectasis caused by bronchial
mucous plugs or particulate aspiration
9. Semi-upright position helps maintain FRC.

PONV (Post Operative Nausea and Vomiting):

Q.7) a) what are the common risk factors for PONV?. b). How would you manage
(PONV).

a) RISK FACTORS FOR PONV

Patient factor:
1. Young age.
2. Female gender, particularly if menstruating on day of surgery of in first
trimester of pregnancy.
3. Large body habitus (obesity)
4. H/O prior postoperative emesis.
5. H/O motion sickness.

Anesthesia techniques:
1. General anesthesia
2. Drugs (Opioids, Volatile agents, ? Neostigmine).

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Surgical procedures:
1. Strabismus (squint) surgery 4. Orchiopexy
2. Ear surgery 5. Tonsillectomy
3. Laparoscopy 6. Ovum retrieval

Postoperative factors:
1. Postoperative pain
2. Hypotension.

b) MANAGEMENT: Aim: Reassure correct vital signs adequate analgesia and

hydration
1. Propofol anesthesia PONV incidence.
2. H/O smoking also PONV
3. 5-HT3 antagonist Ondansetron 4mg (0.1mg/kg children)
Granisetron,(an antiemetic used in conjunction with cancer chemotherapy)
Dolasetron, prevents and treat established PONV
4. ODT (orally disintegrating tablets) preparation of Ondansetron post discharge PONV
5. Metoclopramide 0.15 mg/kg I/V Extra-pyramidal SE
6. Dexamethasone 4-10mg (0.1 mg/kg in children) for refractory PONV
7. Adequate hydration 20 ml/kg and stimulation of P6 acupuncture point.
8. Droperidol I.V. Prolong QT interval fatal arrhythmias not used

VOMITING CENTRE: Lateral reticular formation of medulla, closed to 4 th ventricle.

PONV pathway:
Afferent: CTZ vestibular apparatus cerebellum higher cortical and
brainstem centers solitary tract nucleus.
Efferent: CN V, VII, IX, X, XII and spinal nerves to GI tract, diaphragm and
abdominal muscles

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CTZ chemoreceptor trigger zone (area postrema), floor of 4th ventricle (poorly developed
BBB)
1st line hyoscine, cyclizine and metaclopromide
2nd line 5 HT3 antagonist
3rd line combination or refractory Dexamethasone

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ALDRETE RECOVERY SCORE:
Q8- write down discharge criteria form PACU and ambulatory surgery

POSTANESTTHETIC ALDRETE RECOVERY SCORE

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 2
Shallow but adequate exchange freely Dyspnea, shallow or 1
Apnea or Obstruction limited breathing Apnea 0
Circulation
Blood pressure within 20% of Blood pressure 20 mmHg of 2
normal normal 1

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Blood pressure within 20-50% of Blood pressure 20-50 mmHg of 0
normal normal
Blood pressure deviating > 50% Blood pressure more than
form normal 50mmHg

Consciousness
Awake, alert, and oriented Fully awake 2
Arousable but readily drifts back to Arousable on calling 1
sleep Not responsive. 0
No movement
Activity:
Moves all extremities. Same 2
Moves two extremities. Same 1
No movement. Same 0

Note:
Ideally the patient should be discharged form PACU when the total score is 10 but a
minimal of 9 is required
Majority meats discharge criteria within 60 min in PACU.

Post anesthesia discharge scoring system (PADS):

DISCHARGE CRITERIA AFTER AMBULATORY SURGERY

Post anesthesia discharge scoring system (PADS)

Criteria: Points

Vital signs:
Within 20% of preoperative baseline 2
Within 20-40% of preoperative baseline 1
>40% of preoperative baseline 0

Activity level:
Steady gait, no dizziness, at preoperative level 2

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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 medications 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

Fever: TACHYCARDIA:
PERIOPERATIVE CAUSES: PREOPERATIVE CAUSES
1. Infections 1) Anxiety
2. Drug reactions 2) Pain
3. Blood reaction. 3) Fever
4. Tissue destruction 4) Hypoxemia
5. Connective tissue disorder. 5) Hypercapnia
6. Granulomatous disorder. 6) Hypotension
7. Trauma 7) Anemia
8. Infarction 8) Hypovolaemia
9. Thrombosis 9) CHF
10.Neoplastic disorders 10) Cardiac Tamponade
11.Thyroid storm 11) Tension pneumothorax
12.Adrenal (Addison crisis) 12) Thromboembolism
13.Pheochromocytoma 13) Anticholinergics
14.Malignant hyperthermia 14) B-agonists e.g. salbutamol
(ventolin)
15.Acute gout 15) Vasodilators e.g. GTN
16.Acute porphyria 16) Allergy

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 17) Drug withdrawal
18) Hypoglycemia
19) Thyrotoxicosis
20) Pheochromocytoma
21) Adrenal crisis
22) Carcinoid syndrome
23) Acute porphyria

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