Postoperative Recovery Notes

Post-anesthesia Care Unit (PACU) Overview

  • Post-anesthesia care unit (PACU) is a specialized area for patients recovering from anesthesia.

  • Patients may move to lower intensity recovery settings if they meet PACU discharge criteria, regardless of anesthetic type: deep sedation, regional anesthesia, or general anesthesia.

Admission to the PACU

  • Upon PACU admission, a comprehensive report by the anesthesiologist is essential and should include:

    • Underlying medical conditions, chronic medications, previous surgeries.

    • Medication allergies, current fasting status, and premedications administered.

    • Details of the surgical procedure and types of anesthetics used.

    • Time and dosage details for opioids, muscle relaxants, reversal agents, and local anesthetics.

    • Estimated blood loss, urine output, and fluid replacement information.

    • Intraoperative vital signs and lab findings, noting any unexpected events.

    • List of other medications (e.g., steroids, diuretics, antibiotics).

    • Assessment of airway patency, ventilatory adequacy, consciousness level, and pain level.

    • Anticipated problems involving cardiovascular, respiratory, or renal systems.

    • Information on indwelling devices such as IV or epidural catheters.

    • If intubated, details on endotracheal tube positioning and extubation plans.

    • Orders for any necessary therapeutic interventions and diagnostic test requests.

Monitoring Procedures

  • At a minimum, the following vital signs and parameters should be documented upon PACU admission, then reassessed every 15 minutes:

    • Airway patency, ventilation adequacy, oxygen saturation.

    • Level of pain, initial temperature, and consciousness level.

    • Neuromuscular functioning, hydration status, and nausea level should be checked upon admission and pre-discharge.

  • Continuous monitoring is required:

    • Use of pulse oximetry and a single-lead electrocardiogram is standard.

    • Capnography should be utilized as appropriate, with diagnostic tests ordered when necessary.

Discharge Criteria from the PACU

  • Patients must meet established discharge criteria to ensure they can handle minor post-discharge deterioration:

    • Orientation and adequate muscle strength for minimal self-care.

    • Control of nausea, vomiting, agitation, and pain.

    • Temperature greater than 97°F, resolution of shivering.

    • Urine output greater than 30 mL/hr; ventilatory rate between 10-30 breaths/min.

    • SpO2 levels must exceed 93%, with acceptable airway patency and intact protective reflexes (e.g., swallow, gag).

    • Monitoring for surgical complications (e.g., bleeding, edema) and pre-existing condition exacerbation.

    • Results of tests must be appropriate and considered for destination unit suitability.

Postoperative Nausea and Vomiting (PONV)

  • PONV is a prevalent and significant issue within the PACU:

    • Symptoms can contribute to elevated heart rate, blood pressure, and central venous pressure, increasing morbidity risk.

    • Gagging and retching can trigger parasympathetic responses leading to bradycardia and hypotension.

  • Serious causes for PONV should be ruled out:

    • Examples include hypotension, hypoxemia, hypoglycemia, or increased intracranial pressure (ICP).

  • Treatment options:

    • Often effective to combine different agents targeting various action sites (e.g., Ondansetron (4 mg) alongside Dexamethasone (4-8 mg)).

    • Supplemental oxygen and hydration may ease PONV incidence, although immediate postoperative drinking may trigger nausea.

Ability to Void and Oliguria in the PACU

  • Oliguria is defined as urinary output of ≤0.5 mL/kg/hr and may represent normal renal adjustment to hypovolemia or abnormal renal function following severe intraoperative hypotension or cross-clamping.

  • Urinary retention is often observed after:

    • Opioid administration, neuraxial anesthesia, or specific surgical procedures on the urogenital areas.

  • A portable ultrasonic bladder scanner proves helpful in discerning between the inability to void versus oliguria, aiding in appropriate intervention.