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POST ANESTHESIA CARE UNIT


(PACU)
Department of Anesthesiology &
Reanimation
School of Medicine Pattimura University/
Ambon

LOGO

Design of PACU

Near the operating room and other


Intensive Care facilities
Open ward (to facilitate observation of all
patients simultaneously)
well lighted (day light)

Equipment

Pulse oxymetri
ECG
BP monitor
Warming/cooling blanket
Emergency trolley
outlets : oxygen, electrical, suction
minor set
infusion/syringe pump

Before world war II


Post operative death after anesthesia
and surgery is high
This period is characterized by relatively
high incidence of potentially life
threatening.
Respiratory and circulatory
complications.
After world war II
Success of RR factor in evaluation of
modern ICU/PACU

Staffing

Nurses - trained in care of emerging


Patients ( ACLS)
- I Nurse for 2 Beds ( Patients )
Medical direction of an Anesthesiologist
Coordinated to Surgeon and any
consultants

Emergence from Anesthesia

Because post operative is a time of


great physiologic stress.
Ex.. - Airway obstruction
- Shivering
- Vomite ...etc.
Delayed Emergence
When the patients fail to regain
consciousness 60-90 minute following
general anesthesia ( G.A.)

The causes

Residual Anesthetic
Sedative
Prolong effect of opiate
Hypothermia
Metabolic Disturbances
Perioperative stroke (rare)

Post op/post anesthesia


Management

Monitoring: - vital sign

- BP
Pulse/HR
RR

- Oxygen supplementation (SpO2)


- Temp
- Sensory and motor level
(Regional Anesthesia)

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

Defined as PaO2 < 70 mmHg


Causes
- Hypoventilation
- Oxygen consumption
- FRC
- Lung - edema

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

INTENSIVE CARE UNIT (ICU)


- Multi disciplinary
- As intensive care with potentially
life
threatening illness
- Supporting therapies
- neurologic
cardiovascular/hemodynamic
- Pulmonary/respiratory
- Electrolyte/metabolism
- Nutritional

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)

ACUTE CNS INJURY


- Ischemia (focal or generalize)
- Structural distortion of brain
- Scoring GCS
- CNS support is focused on
- optimizing systemic & cerebral
B.F
- normalizing 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
*

Oxygen Delivery (D O2)


D O2 = Ca O2 x C O x 10
= (HB x 1.34 x Sa O2)
+ (PaO2 x 0,031) x
C. O x 10

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)

- Vaso Pressor & Inotropic


Agent
- Dopamine. etc
- Antibiotic
- Decrease Oxygen Demand

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

CLINICAL MANIFESTATIONS OF ARF


IS ARDS
- Onset 12-72 hours after triggers
- Respiratory distress (gasping, cyanotic
etc)
- Lung edema (non cardiogenic)
- PaO2 < 50mmHg
- CPWP > 18mmHg
- PaO2/FiO2 < 200mmHg
Management
- Oxygen supplement
- nasal canula
- face mask
- IPPV non invasive

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

2. HYPERKALEMIK ( K+>5,5 mEq/L


- Most often from renal
dysfunction
- Other Causes
- Acidemia
- Hypoaldosteronism
- Cell Death (Hemolysis,
Burns etc)
- Excessive
Intake
Clinical - Arrhythmias
- Muscle Weakness
- Paralysis. etc.

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

3. SODIUM (N 135 - 145 mEq/L)


1. Hyponatremia (Na + < 135 mEq/L)
Causes
- Excess Secretion of ADH
- Non Sodium Solute Infusion
Clinical.
- CNS Disturbances
- Muscular Disturbances

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

2. HYPERNATREMI (Na + > 145 mEq/L)


Cause Intracellular volume
Depletion with
A Loss of free water
- Excessive sodium intake
Clinical
- CNS
- Muscle

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

IF Glucose Level 250 Mg %


- Glucose Containing Fluid (1/V)
(Maintain Glucose level >150
By Insulin S.C.
IF Glucose Level < 150 mg %
- Glucose 10 %
IF PH < 7.0
- Consider Bicarbonate
- Correcting the Serum level (if
Present)
- Potasium
- Phosphorus

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