Anesthesia Recovery and Postoperative Recovery and PACU Management Notes

Learning Objectives for Anesthesia Recovery

• Create an appropriate postoperative plan for care for the surgical patient.
• Determine the appropriate patient monitoring and care needs during transport from the operating room for the healthy patient.
• Provide a postanesthesia care report.
• Complete an anesthetic record.

Functions of the Postanesthesia Care Unit (PACU)

• Monitor and care for patients who are recovering from the immediate physiologic effects of anesthesia.
• Administer medications, fluids, and blood products as needed for patient stabilization and recovery.
• Perform and assess diagnostic studies based on clinical need:
  • Laboratory tests.
  • Electrocardiogram (ECG).
  • Chest X-ray (CXR).
• Manage postoperative complications that arise during the immediate recovery phase.
• Assess patient readiness for discharge to appropriate locations.

PACU Monitoring Standards and Requirements

• Respiratory function monitoring:
  • Continuous pulse oximetry ($SpO_2$).
• Cardiovascular function monitoring:
  • Continuous ECG.
  • Blood Pressure (BP) measurement every $5$ to $15$ minutes.
• Neuromuscular function:
  • Observation is standard unless specific impairment is suspected.
• Temperature monitoring:
  • Routes: Oral, axillary, temporal, or tympanic.
• Periodic assessment and monitoring of additional clinical parameters:
  • Mental status.
  • Pain levels.
  • Nausea and vomiting.
  • Fluid assessment.
  • Urine output and voiding.
  • Drainage and surgical site bleeding.

Effective Clinical Communication: SBAR

• S: Situation.
• B: Background.
• A: Assessment.
• R: Recommendation.

Case Study: Pediatric Tonsillectomy and Adenoidectomy

• Patient Profile:
  • $13$-year-old female.
  • Scheduled for elective Tonsillectomy and Adenoidectomy.
  • Status: NPO.
  • Medical History: Obstructive Sleep Apnea (OSA), Morbid Obesity.
  • Measurements: Height $5'3''$, Weight $190\,lbs$.
• Postoperative Event ($4$ hours later):
  • Patient appearance: Weak and lethargic.
  • Airway: Blood noted in the airway.
  • Vital Signs:
    • BP: $66/33\,mmHg$.
    • HR: $133\,bpm$.
    • $SpO_2$: $95\%$.
    • RR: $28\,bpm$.
• Clinical Considerations: Identification of differential diagnosis, determination if the situation constitutes an emergency, and assessing if age is a contributing factor.

STOP-BANG Sleep Apnea Questionnaire

• Scoring System (Chung F et al Anesthesiology $2008$ and BJA $2012$):
  • STOP:
    • Snore: Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?
    • Tired: Do you often feel tired, fatigued, or sleepy during daytime?
    • Observed: Has anyone observed you stop breathing during your sleep?
    • Pressure: Do you have or are you being treated for high blood pressure?
  • BANG:
    • BMI: Is BMI more than $35\,kg/m^2$?
    • Age: Is age over $50$ years old?
    • Neck: Is neck circumference greater than $16$ inches ($40\,cm$)?
    • Gender: Is the patient male?
• OSA Risk Classification:
  • High risk: Total score of $5$ to $8$.
  • Intermediate risk: Total score of $3$ to $4$.
  • Low risk: Total score of $0$ to $2$.

Case Study: Laminectomy and Fusion

• Patient Profile:
  • $70$-year-old male, weight $120\,kg$.
  • Procedure: Laminectomy and Fusion $T12$-$-L5$.
  • Medical History: Hypertension (HTN), COPD, Automated Implantable Cardioverter Defibrillator (AICD), CPAP use, AKD.
  • Social History: Smoker with a $20$ year pack-per-day (PPD) history.
  • Management Note: Neuromonitoring Advised.

Case Study: Abdominal Aortic Aneurysm (AAA)

• Patient Profile:
  • $85$-year-old male, weight $90\,kg$.
  • Diagnosis: $8\,cm$ AAA found on routine visit.
  • Medical History: Diabetes Mellitus (DM), well-controlled HTN, GERD, Prostate Hyperplasia, Hyperlipidemia.
  • Respiratory Profile: $80$ pack/year smoking history, COPD, Dyspnea on Exertion (DOE) with average chores.
  • Surgical Plan: Endovascular AortoBifemoral Stent with potential conversion to open surgery.
• Management Priorities:
  • Preoperative concerns and assessment of perioperative risks using tests.
  • Intraoperative anesthetic management focuses: The most important goal is managing patient comorbidities, ensuring blood and blood products are available for potential conversion, and readiness for all contingencies.

PACU Discharge Destinations and Care Levels

• Home.
• Clinical Ward / Hospital Room:
  • Nurse-to-patient ratio: $1:4$ to $1:6$.
  • Capability: Some units offer non-invasive continuous monitoring such as telemetry and pulse oximetry.
• Intensive Care Unit (ICU):
  • Nurse-to-patient ratio: Lowest ratio at $1:2$.
  • Capabilities: Continuous invasive cardiopulmonary monitoring, mechanical ventilation, and performance of certain surgical procedures.
  • Arrangements: ICU or hospital bed admission is typically arranged by nursing staff at the request of the anesthesiologist or surgeon.
• Classification: A procedure is defined as "outpatient" or "in-patient" based on the discharge destination, not the pre-admission status.

Criteria for Hospital Bed Admission

• Rules of Thumb for Admission:
  • Risk of serious postoperative complications requiring immediate treatment (e.g., hemorrhage, exacerbation of preexisting illness, airway compromise, neurologic injury).
  • Requirements for a hospital setting for treatment (e.g., frequent assessment of diagnostic studies, IV medications).
• Administrative Determination:
  • Admission is usually determined by the admitting physician (Hospitalist or Surgeon), with Anesthesia providing insight into health status.
  • Patients are referred to as "in-patient" regardless of whether they were previously admitted or arrived from home (AM Admit).
• ICU Specific Criteria:
  • Requirement for a ventilator.
  • Need for invasive monitors: Arterial lines, Central Venous lines, or Pulmonary Artery catheters.
  • Administration of vasoactive medication infusions.

PACU (Phase I) Discharge Criteria

• Blood Pressure and Heart Rate within $20\%$ of preanesthesia levels.
• Ability to ambulate (if applicable).
• None or minimal Nausea and Vomiting (N&V).
• Pain controllable with oral analgesics.
• Surgical bleeding consistent with expectations and appropriate hemostasis.
• Adequate urine output.

Phase II Recovery

• Definition: A less intensive level of care used for patients scheduled for discharge to home.
• Monitoring: Usually limited to an initial set of vital signs and nurse observation.
• Fast-tracking: Healthy patients undergoing minor, short-duration procedures may bypass Phase I and go directly to Phase II if they meet established criteria.
• Availability: Not available at all facilities.

Monitoring and Care During Transport

• General Principles:
  • Care should be physiologic systems-based.
  • Increased monitoring for known impairments or systems at risk.
  • A careful assessment of systems is required prior to transport.

Respiratory System Management During Transport

• Oxygenation:
  • Assessment: $SpO_2$.
  • Treatment: Current recommendations suggest all patients receive supplemental oxygen for transport. The delivery device and $FiO_2$ should match patient needs. Severe impairment may require continued positive pressure mechanical ventilation.
  • Monitoring: Observation of color and respiratory effort for those with no significant impairment; continuous $SpO_2$ for those with significant impairment.
• Ventilation:
  • Assessment: Spontaneous Tidal Volume ($V_t$), Minute Ventilation ($V_E$), and End-tidal $CO_2$ ($EtCO_2$).
  • Treatment for Impairment: Obstruction is treated with jaw thrust, Oral Airway (OAW), or Nasal Airway (NAW). Impaired drive or mechanics require Positive Pressure Ventilation (PPV) via Endotracheal Tube (ETT).
  • Monitoring: "Look, Listen, Feel." Look for respiratory effort, listen for obstruction or verbal communication, and feel for expired air. Significant impairment may warrant continuous $SpO_2$ and consideration of $EtCO_2$.

Circulatory System Management During Transport

• Cardiac Output:
  • Assessment: Comparison of heart rate, rhythm, and Non-Invasive Blood Pressure (NiBP). Direct assessment is unavailable without invasive monitors.
  • Treatment: Maintain hemodynamic support using vasopressors, inotropes, fluids, or blood products. Treat arrhythmias with pacemakers or defibrillators.
  • Monitoring: Observation for signs of adequate perfusion for healthy patients; NiBP, ECG, and potentially invasive monitoring for significant impairment.
• Transport Needs for the Healthy Patient:
  • Nasal Cannula or Face Mask.
  • Oxygen cylinder.

Postanesthesia Care Report Components

• Patient identification.
• Surgical procedure performed.
• Patient history, focusing on respiratory and cardiac status.
• Adverse complications (e.g., bleeding, laryngospasms, bronchospasm).
• Fluids and urine status.
• Medications administered, such as opioids and anti-nausea drugs.

Standard Anesthetic Workflow

• Apply basic monitors.
• Administer the anesthetic (General Anesthesia, Regional, or Monitored Anesthesia Care/MAC).
• Institute airway management and support ventilation as required.
• Monitor the patient and maintain homeostasis (fluids, medications, Packed Red Blood Cells/PRBC).
• Withdraw anesthetics.
• Transport the patient to PACU or ICU.
• Provide a comprehensive PACU/ICU report.
• Complete medical documentation in the anesthetic record.