Postanesthesia Care and Post operative Pain Management

Transporting the patient

Airway patency Breathing (rate and depth) Arterial oxygenation (pulse oximeter) Blood pressure Heart rate, ECG Level of spinal or epidural anesthesia Level of consciousness

Care in PACU
Admitting the patient
Supplemental Oxygen Monitoring devices (Pulse oximeter, ECG, Temperature, BP) Anesthesiologists report

Report on admitting a patient to PACU

Name Brief medical history Operation Anesthetic Summary of fluid balance Expected problems and plans

Common Problems in PACU

Delayed Awakening after Anesthesia Residual neuromuscular blockade CNS disorder Residual effects of anesthetic, sedative Other medications Hypothermia Preexisting coma or obtundation Interpatient variation in response to anesthetics

Agitation and Delirium

Hypoxemia or airway obstruction Pain Full bladder Incomplete reversal of neuromuscular blockade Withdrawal from alcohol or other drugs Residual anesthetics or sedatives Senile dementia

Pain
Operative site Muscle spasm Bladder distention Musculoskeletal Tight case or dressing

Nausea and vomiting

History Gastric distention Full stomach before operation Opioids Operations

Residual Neuromuscular Blockade

Evaluate any patient with unexplained upper airway obstruction, hypoventilation or delayed awakening after general anesthesia for residual NM blockade Rule out the diagnosis through head or leg lift test for 5 seconds Treat with additional neostigmine or other anticholinesterase

Causes of Airway Obstruction

Somnolence Residual weakness Obtunded airway reflexes Upper airway edema Sleep apnea Obesity Partial airway obstruction preoperatively

Signs of Airway Obstruction

Noisy breathing Dyspnea Cyanosis Hypoxemia CV abnormalities Tracheal tug Nasal flaring Rocking motions of the chest

Treatment of Airway Obstruction

Reposition head and neck Oxygenation Jaw thrust Nasal and oral airways Tracheal intubation

Hypoxemia
All receive supplemental oxygen on admission Pulse oximeter is mandatory Causes of hypoxemia
Atelectasis Aspiration pneumonitis Pnemothorax Pneumonia Pulmonary edema

Respiratory Depression
Causes
Residual drug effects Airway obstruction COPD Increased CO2 production (shivering and fever) Opioids

Treatment
Oxygenation Stimulation Assisted or controlled PPV Naloxone if due to opioids

Hypertension
Causes
Preexisting hypertension Anti hypertensive medicine not taken Pain Distended bladder Volume overload Emergence delirium Hypothermia with vasoconstriction Hypoxemia,hypercarbia

Hypotension
Causes
Hypovolemia Residual effects of subarachnoid block or epidural anesthesia LVF Sepsis Pulmonary embolus Tension pneumothorax

Hypothermia
Effects
Delays emergence Impairs organ function and coagulation Exacerbates htn Increase O2 consumption Increase demand in CO

Management
Warm the OR Use warming blankets or active heating devices Warm intravenous fluids

Fever
Less common than hypothermia Common cause is pulmonary atelectasis Less common cause is febrile reaction to drugs and blood transfusion Rare: malignant hypertension

Elements of Postanesthetic Visit

Patient satisfaction What patient remembers during the induction? Adequacy of pain relief Review outcome of special problems (back pain, nausea and vomiting) Any other complaints

Thank you!!!