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Design of PACU
Equipment
Pulse oxymetri
ECG
BP monitor
Warming/cooling blanket
Emergency trolley
outlets : oxygen, electrical, suction
minor set
infusion/syringe pump
Staffing
The causes
Residual Anesthetic
Sedative
Prolong effect of opiate
Hypothermia
Metabolic Disturbances
Perioperative stroke (rare)
- BP
Pulse/HR
RR
Pain control
- parenteral
- Regional anesthesia
- Nerve Block
Agitation/Restlessness
- cause ? (hipoxemia, acidosis
etc)
Nausea and vomiting
cause ? hypotension by
- regional anesthesia
- opioid
- vagal tone
Shivering
cause ?
- Unwarmed I.v. fluids
- Exposure of large wound
- AC
- Hyperthermia
- Metabolic acidosis ect
Complications in PACU
1. Airway obstruction
- Unconscious patients
tongue
falling
back against the posterior
pharynx
- Larynx spasm
- Glottic edema etc
2. Hypoventilation
- Defined as PaCO2 > 45 mmHg
pH < 7,25
- Causes
- Residual depressant effect of
anesthesia agents
(overdose)
- In adequate reversal
- Severe pain
- Tight abdominal dressing
- CO2 production is high
3. Hypoxaemia
4. Hypotension
- Defined as A 20-30%
reduction of
BP
- Causes
- Hypovolemia
- Ventricular
dysfunction
- Impaired cardiac
filling
5. Hypertension
Defined as BP > 20-30% of base
line
Causes
Sympathetic activation
- pain
- hypercapnia
6. Arrhythmia
- Hypercarbia
- Electrolyte disturbances
- Residual effects of
cholinesterase
inhibitor
Discharge criteria
- must be evaluated
- after 60 minutes in the PACU
_________________________________
____
Parameters
Value
_________________________________
___
color - pink
2
- pale
1
- cyanotic
0
_________________________________
____
Circulation
BP within 20% of normal
2
20-50%
1
50% from normal
0
____________________________________________
_____
Consciousness
- awake/alert
2
- arousable
1
- no response
0
NEUROLOGIC SUPPORT
- CBF is constant auto
regulation
at range of BP (MAP 50150mmHg)
- Injury losses of ability
autoregulation
- CBF related to CPP
(CPP = MAP-ICP)
-Immediate concerns
- airway/ventilation/oxygenation
- hemodynamic issues
-Hypotension (loss of automatic
control)
- Hypertension (hyper adrenergic
state)
- Cardiac dysfunction
- Seizures control
(metabolic/infections)
- Neurologic exam
- Is there a surgical lession ?
SUPPORTIVE CARE
- General treatment
- Oxygenation
- Correct anemia
- Hemodynamic stability
- Establish normovolemia
- Control hyperthermia
- Control seizures
- control pain
- Avoid agitation/shivering
- correct metabolic abnormalities
-Control ICP
- CSF (volume reduction)
- Hyperventilation
- Osmotic agent
- Barbiturate
- Head position
- To be prevent vasospasm
- Steroid (?)
CARDIOVASCULAR/HEMODYNAMIC
SUPPORT
- Major determinants of cardiac output
(C.O)
- Heart rate & Contractility
- Blood Vessels
- Volume Intra vascular
- Pre Load
- After Load
- Oxygen Delivery
- C O = HR x 3 V
SV Is Determined By
- Preload
- After load
- Contractility
* Clinical Measurements
- Preload - Echo Cardiography
- PCWP
After load = SVR
= MAF - CV x 80
C. O
Contractility = ECHO = EF
*
SHOCK
* Characterized BV
- Organ Blood Flow that Is
Inadequate
to meet Tissue Demands
* Four Categories Of Shock
1. Cardiogenic Shock
- Co
- PCWP
- SVR
2. Hypovolemic Shock
- CO
- PCWP
- SVR
3. Distributive Shock
- CO
N/
- PCWP N /
- SVR
4. Obstructive Shock
- CO
- PCWP
-SVR
MANAGEMENT OF SHOCK
- Increasing C.O
- Therapy Arrhythmias
- To Manage - Pre Load
- After Load
- Fluid
- Improve Contractility
- Optimize Oxygen Delivery
- Hemoglobin
- P a O2 (FiO2 & Lung Function)
Respiratory Support
One of Most Common Disorder
Leading to 1cm Admission is ARF
(Acute Respiratory Failure)
ARF. - When the Pulmonary system is
no
longer able to meet the
metabolic
demands of the
body
Two types of respiratory failure (RF)
Type I Hypoxemic RF (PaO2 50TORR)
Type II Hypercapmic RF (PaCO2 50
TORR)
Causes of RF
Type I (Usually the result of mismatch
of
alveolar ventilation and
pulmonary
perfusion)
Example - Acute lung injury
- acute pulmonary edema
Type II (Characterized by alveolar
hypoventilation)
Example airflow obstruction
- CNS
- Neuromuscular
disturbances
ELECTROLYTE DISTURBANCES
Es the most common disturbances are
in K+ Na+ Ca+
A. Potassium (N.3,5-5,5 mEq/L)
1. Hypokalemia (K+ < 3,5 mEq/L)
Causes - Renal & extra renal
losses
- Transcellular shift
- Decreased intake
Clinical Arrhythmias
- ECG. Abnormalities
- Muscle Weakness
- Ileus Etc.
TREATMENT
- Correcting The Underlying
Cause
- Stop Offending Drubs
- Correct The Potassium level
- K + > 3 Meg /L . KCL 20-40
Meg/4-6 MRS .
Orally/NGT
- K + <2,5 Meg /L KCL 20-30
Meg
/HRS
Intravenously
TREATMENT
- Underlying cause
- Stop Offending Drugs
- Limitation of Potassium
- Correcting
- ECG Abnormalities are present
- CaCl2 10 % 5-10 ml (i.v.5-10 mnt)
- Sodium Bicarbonate
1 Meg /Kg BW /I.V 5-10 mnt.
- 10 IU RI. In 10 Ml Dext.50 %/IV/10
- Dialysis
TREATMENT
- Treating the Underlying Disease
- Stop Offending Drugs
- Correcting
- Restricting free water intake
- Increasing free water clearing
- Loop diuretic
- Replace with saline 5 %
- Limit 15 mEq/L in first 24
hours
TREATMENT
Underlying Causes
Free water Repletion
L = 0,6 x wt [( Na1 /Na2)-1]
L = Water deficit
Na 1 = Normal Sodium Level
Na 2 = Measured
Wt = KS
- Correcting . 12-20 Meg /C/24HRS
- Dialysis
METABOLIC DISTURBANCES
Hyperglycemic Syndromes
- Life Threatening Hyperglycemic
syndrome
1. Diabetic Ketoacidosis (DKA)
2. Hyperglycemic Hyperosmolar
Nonketotic
syndrome (H1 + NK)
Clinical
- Osmotic Diuresis Dehydration
- Weakness
- CNS Manifestation
- Odor to the Breath
TREATMENT
- The Goals are
- Restore the Fluid & Electrolyte
Balance
- Provide Insulin
- Identify Precipitating Factor
- NS. 20 ml/ kg for First Hour
Then. 250-500 ml/Hr AS Needed
After that
- NS 0,5 % Maintenance
-Insulin (R1) 5-10 IU
Followed By 5-10 IU /HR. (0,1 IU