Introduction

The postanesthesia care unit (PACU) or recovery unit is the place where patients go to after leaving the operating room (OR) and before being discharged home or to the wards. Monitoring the patients for common complications is of utmost importance in the immediate postoperative period. This requires the presence of trained personnel and staff that can quickly identify common problems and treat the patient. Patients must have a return to baseline before getting discharged home. Emergency equipment and drugs should be readily available at all times.

Phases of Postoperative Care

The PACU, recovery room, or postoperative care unit are staffed by nurses specifically trained in the care of patients who have just received general, neuraxial, or peripheral blocks or monitored anesthesia care types of anesthesia. They should have expertise in recognizing and handling the most common complications after surgery. Nurses in the PACU are trained in airway management skills and must be certified in advanced cardiac life support. Usually patients in the PACU are under the medical direction of an anesthesiologist [1, 2].

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  Phase 1: Marks the beginning of the immediate postoperative period. Typically, nursing care is one nurse to two patients. It is the position of the American Society of PeriAnesthesia Nurses (ASPN) that the number of patients assigned to a nurse in phase 1 should depend on multiple factors, including acuity level, complexity of care, comorbidities, and the American Society of Anesthesiologists (ASA) status, among other factors [2]. Vital signs are recorded every 15 minutes or more often if the patient condition warrants. In some institutions, critical care patients go directly from the OR back to the intensive care unit (ICU), bypassing the PACU.

  
  
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  Phase 2: Typical staffing consists of one nurse to three patients. Some monitored anesthesia care (MAC) cases performed on ASA I or II patients can be fast-tracked into phase 2 directly from the OR. During this phase, the patient and caregivers are educated for care at home or prepared for extended observation.

  
  
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  Phase 3: It is an extended care phase staffed by one nurse to 3–5 patients. Patients are ready to leave the recovery unit but might wait here until a bed is available.

ASA Standards for Postoperative Care

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   1. Postanesthesia management should be provided to any patient receiving MAC or regional or general anesthesia. An anesthesiologist should be responsible for the supervision and care of PACU patients.

   
   
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   2. The patient should be transported by a member of the anesthesia care team who can continually monitor, evaluate, and treat any condition that might arise until handing off to the PACU nurse.

   
   
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   3. A verbal report should be provided to the nurse receiving the patient that includes the patient’s past medical history, allergies, relevant home medications, surgery undergone, any airway issues, intraoperative course and medications or infusions, pertinent laboratory results or radiological film reports, fluid balance, blood products administered, lines and intravenous cannulae or intravenous catheters, whether peripheral or central, regional or neuraxial procedures, complications, concerns, and pending tasks for the immediate postoperative period. This is the moment when the nurse is alerted about any particular concerns.

   
   
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   4. The patient will be continually evaluated in this setting by the nurse for any signs of deterioration. Vital signs are recorded at set intervals, including arterial saturation, blood pressure, respiratory rate, cardiac rhythm, temperature, and mental status. Assessment of pain, nausea, and vomiting should be routine during emergence and recovery.

   
   
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   5. A physician is responsible for discharging the patient from the PACU, and the name should be noted on the record [3].

Transport and Delivery to the Postanesthesia Care Unit

Patients should receive supplemental oxygen during transport to delay the hypoxemia that can ensue from residual effects of anesthetics, opioids, and neuromuscular blocking agents administered. Depending on the stability of the patient, a pulse oximeter, ECG, and blood pressure monitors may suffice for transport. Vigilance is always required. Upon arrival to the PACU, a report is provided to the nurse as described previously. The anesthesia provider places orders for any patient’s needs that might arise such as pain and antiemetic medications. Also, orders for supplemental oxygen and neuraxial anesthesia when applicable should be available. Monitoring of vital signs at regular intervals, usually every 5 minutes and then every 15 minutes, continues. The patient’s breathing patterns, airway patency, respiratory rate, saturations, blood pressure, temperature, pain, and level of consciousness are routinely assessed.

Most Common Problems Encountered in the PACU

Surgery can trigger inflammation due to tissue damage, and anesthesia can cause alterations in hemodynamics that can further compromise organs. Whether patients are healthy or not, many systems are affected by these alterations, giving rise to potential problems (see Table 10.1).

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   1. Hypertension: The goal is to identify the most probable cause and treat accordingly. The patient might be asymptomatic or complain of visual changes or headaches, or can feel short of breath and restless. Some blood pressure medications are held prior to surgery. If this is the case, consider restarting. Always review the patient’s chart to look at the baseline pressure to target your goal. Also, consider the context and note any other associated signs and symptoms that might point you to a different source. For instance, examine the pupils and alertness level, which can help you rule out a developing intracranial pathology. Ask the patient if they are having pain and use a number scale, for instance, to quantify. If so, titrate pain medication to effect. By looking at the history, you can verify if the patient has a history of alcohol or drug abuse contributing to withdrawal signs. Consider fluid overload or transfusion-associated cardiac overload. Examine the suprapubic area if the patient has had no urine output after neuraxial anesthesia. A bladder ultrasound can be helpful. Revise the drugs given to the patient recently, and make sure that vasopressor infusions are held or checked for correct concentration and dosing.

   
   
2. 
   

   2. Hypotension: Keep in mind that cardiac output will depend on heart rate and stroke volume. Blood pressure is the product of cardiac output and systemic vascular resistance. One way to approach this is by considering whether the patient is volume-depleted, there is a delivery problem, the vessels are dilated, or the pump is failing. This can give you a start on how to navigate and find the culprit. Check the intraoperative record for fluid balance and estimated blood loss. Review the urine output and recent laboratory results, including hemoglobin. Look at the drains and surgical incisions for swelling or frank bleeding. If the lungs sound clear, consider a fluid bolus and observe the response. Consider whether your patient can tolerate the Trendelenberg position while you continue to troubleshoot. Be mindful of patients who are known to have poor cardiac and/or valvular dysfunction, as deterioration can rapidly ensue after a fluid challenge or changes in position. Consider recently dialyzed patients who are volume-depleted. Look at the ECG for conduction abnormalities; ask the patient if they have chest pain, and look for other signs that can suggest a cardiac event. Also, consider allergic/anaphylactic reactions and examine the skin; listen for stridor, and look for signs of angioedema. If the patient had neuraxial anesthesia, review the details on record. In the case of a patient who received a blood transfusion, consider a transfusion reaction. In patients who had a procedure at the electrophysiology laboratory or trauma patients, consider tamponade. Consider pneumothorax, and examine those patients who had regional blocks, central lines, laparoscopic surgery, and trauma to the chest, for example. For those on a ventilator, check the positive end-expiratory pressure (PEEP) settings. Sepsis can already be present in many patients who come to the OR, including those with obstructive kidney stones, and also in patients with burns and necrotizing fasciitis, among others. Look for a transesophageal echocardiogram in the chart, if available, and consider a cardiac consult for cardioversion if deemed appropriate. Consider antiarrhythmics and inotropic agents, and consider placement of invasive monitors such as an arterial line for continuous monitoring and for frequent laboratory draws when appropriate. When persistent hypotension ensues despite treatment, consider adrenal causes and hypothyroidism and plan for possible transfer to the ICU.

   
   
3. 
   

   3. Arrhythmias: Some benign arrhythmias might be a consequence of electrolyte imbalances. This can be easily ruled out by sending a venous gas sample or, if an arterial line is already in place, by sending an arterial sample. Preexisting cardiac conditions, sympathetic discharge from surgical procedures, and acidosis can also affect electrical conduction through the heart. For bradycardias, consider the residual effects of beta-blockers, reversal agents, and opioids. Sinus bradycardia with a sustained blood pressure usually does not require treatment. Always assess your patient’s mental status and look for other signs or symptoms. Look at the medical record for administered medications. Always verify infusion concentrations, dosages, and pump settings. Also consider the patient’s history, as athletes tend to have normal sinus bradycardia. Irregular bradycardia with long pauses, missed beats, and low blood pressure might be the first sign of a third-degree atrioventricular block. These patients should be placed on a transcutaneous pacing monitor, and cardiology should be immediately consulted for further workup. For those patients who had a pacer or defibrillator setting changes before going to surgery, make sure to restore back to the presurgical settings before discharge home, and ensure that it is working. In the case of tachycardia, rule out pain, fever, low preload state, reversal agents, bleeding, and malignant hyperthermia, among many others.

   
   
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   4. Oliguria/anuria/polyuria: Oliguria is defined as the state in which a patient makes <0.5 mL/(kg hr) of urine. Consider if the patient is not making urine because of intravascular fluid depletion, tubular necrosis at the level of the nephron unit, or obstruction to drainage. The most common cause will be fluid restriction techniques used where the intravascular space remains depleted. Consider administering a fluid challenge of 250–500 mL of crystalloid, and assess. Special precaution and slow infusion are recommended for patients known to have poor cardiac function or renal failure. A physical examination and chart review for laboratory results and context should take place. Administration of diuretics might not be indicated in every case and the effects will be temporary if the injury is at the level of the nephron. In this last scenario, further investigation by a specialist might be indicated. Renal hypoperfusion, toxins, and trauma might be responsible for intraparenchymal damage to the kidneys. Lastly, it is important to check that if a foley catheter is in place, it is not obstructed or dislodged. After prostate surgery, for example, large amounts of clots might obstruct drainage. Anuria is more commonly seen in known advanced stages of renal failure in patients undergoing dialysis. Sometimes it can also be seen as a result of a spinal anesthetic. In this case, straight catheterization is recommended until the spinal anesthetic wears off and the bladder regains normal function. Polyuria is seen after large volumes of fluid administration, diuresis with furosemide or osmotic diuretics, diabetes insipidus, and nonoliguric renal failure. It is important to monitor these patients for hemodynamic instability and electrolyte imbalances.

   
   
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   5. Delirium: Most commonly seen in the elderly population, those with preexisting dementia and psychiatric disorders, and drug-dependent patients. These patients present very agitated as they emerge, often requiring multiple persons to keep them from harming themselves. They can also be lethargic and disoriented. A number of drugs have been cited as a contributing factor, such as benzodiazepines, anticholinergics, opioids, large doses of metoclopramide, and ketamine, among others. It is important to rule out hypoxemia as the cause of agitation, bladder distension, electrolyte derangements, preexisting encephalopathies, preexisting delirium, and brain injuries, among others.

   
   
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   6. Stroke: Certain surgeries have a higher incidence of stroke. Cardiac, carotid, and intracranial surgeries, as well as polytrauma patients, have the highest risk. Vigilance and good clinical judgment are critical to recognizing some of the signs and symptoms of a stroke. When suspected, the stroke/neuro team should be immediately contacted as the outcomes are directly related to the time to intervention. The patient can present with slurred speech, facial asymmetry, visual disturbances, confusion, and paralysis. Blood pressure and airway control is warranted in some instances. Look for any recent administration of anticoagulants and the presence of dysrhythmias.

   
   
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   7. Somnolence: Hypoglycemia, hypothermia, and hypermagnesemia can lead to somnolence. Do a finger stick to check glucose. Check the temperature and provide the patient with warm blankets. Check magnesium levels to avoid toxicity in those receiving an infusion (preeclampsia). A patient who is hypoventilating, with high carbon dioxide levels, can also become somnolent. Check saturations and draw an arterial blood gas if there is a suspicion of hypercarbia. Always know where your reintubation equipment is, in case you need it.

   
   
8. 
   

   8. Hypoxia: The pulse oximeter should be one of the first monitors to be connected to the patient upon arrival to the PACU. Mild hypoxemia on room air is common in patients recovering from anesthesia. Sometimes airway obstruction by the tongue can be resolved by gentle jaw thrust or a nasal/oral airway. If the neck was a site of surgery, examine the patient for an enlarging neck hematoma and note the output on the drain when present. The attending physician and surgeon should be notified immediately of this, as it might warrant a return to the operating suite. When hypoxia is present, sit the patient up to increase the functional residual capacity if the type of surgery allows for it, and provide supplemental oxygen via nasal cannulae or other device. Titrate the oxygen level to achieve saturations near preoperative levels. Decreases in functional residual capacity and atelectasis are the most common cause of hypoxemia postoperatively. Encourage the patient to take deep breaths and provide suction if needed. Patients with chronic lung conditions might require oxygen supplementation for longer duration. If the patient’s condition does not improve after maximal supplementation via a nonrebreather mask, for instance, and an arterial blood gas sample indicates continuous hypoxemia, consider reintubating the patient. For patients with obstructive sleep apnea, a trial of continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) first might make a difference. Make sure that you have reversed respiratory depressant drugs such as opioids, benzodiazepines, and neuromuscular blocking drugs. Think of the type of surgery the patient just underwent and consider atelectasis, mucus plugs, or gauze left behind in the airway during ear, nose, and throat procedures. Consider a CXR that can rule out the presence of aspiration, pneumothorax, or excess fluid in the lungs. Consider drawing blood to make sure hemoglobin is not at critical levels.

   
   
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   9. Hypercarbia: Hypoventilation leads to hypercarbia, and so does splinting. A patient who becomes hypercarbic (PaCO₂ >60 mmHg) becomes obtunded over time if not treated, which might be the reason why you are called in the first place. Examine the patient; assess their alertness level and listen to the breath sounds. Take note of the breathing pattern and frequency, and note the abdominal and thoracic movements. Revise the medications and the quantities that the patient has received over a period of time. Palpate the patient’s chest in long laparoscopic cases and assess for subcutaneous emphysema. When appropriate and suspected, use reversal agents for opioids, benzodiazepines, and neuromuscular blocking drugs. However, titrate these agents in small increments to avoid increases in sympathetic tone that can lead to hypertension and myocardial ischemia. Patients with obstructive sleep apnea might require assisted ventilation via a mask for a period of time. Assess for hypoventilation due to splinting and pain, and consider regional anesthesia if applicable. Use one of many methods for the patient to score pain. If hypoxia or hypercarbia are left untreated, they might quickly progress to cardiovascular and respiratory collapse requiring a higher level of management.

   
   
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    10. Postoperative nausea and vomiting (PONV): This is a commonly encountered experience, which is multifactorial in nature. Some of the patient factors include young age, female gender, history of motion sickness, or prior history of PONV. Anesthetic factors, such as general anesthesia with volatile agents, nitrous oxide, and use of opioids, are also risk factors. In the case of a spinal anesthetic with sudden hypotension, this can trigger the chemoreceptor trigger zone in the area postrema of the brain, causing nausea. In this latter case, administering drugs that can increase blood pressure, such as phenylephrine, can resolve the symptoms. Some of the surgical procedures that present as a higher risk factor for PONV are strabismus, breast, and laparoscopic surgeries. In general, patients with multiple risk factors should receive prophylaxis as their risk is higher [Reference Gan, Meyer and Apfel4]. Use of multiple agents that act on different receptors is more effective than use of multiple doses of the same class of drug [Reference Gan, Meyer and Apfel4, Reference Apfelbaum, Silverstein and Chung5]. Some examples of the drugs used are dexamethasone, ondansetron, and scopolamine patch. Consider the individual patient and the side effect profile before choosing a drug.

    
    
11. 
    

    11. Pain: The patient with pain will be anxious and clearly uncomfortable, and will manifest high blood pressure and often tachycardia. Multiple scoring systems for pain exist that can be used to help the patient communicate the severity of their pain. This could be due to a failed nerve block, a high tolerance of narcotics due to drug use, or insufficient quantities of opioids given intraoperatively for the type of surgery. Use a combination of nonnarcotics and narcotics to treat pain. Consider a patient’s renal and liver function during your selection, and be aware of whether the patient uses agonist/antagonist medications at home as part of their treatment plan. Consider an intravenous bolus of ketamine on a case-by-case basis or a postoperative regional block if applicable. Sickle cell patients who suffer an acute attack after surgery best respond to Dilaudid.

    
    
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    12. Shivering and hypothermia: Heat gets redistributed from the core to the peripheral compartments, causing hypothermia. Added to this are the vasodilatory effects of anesthetics, the cool ambient temperature, and the large exposure of body parts that can all contribute to significant hypothermia. Shivering is the body’s response to increase its temperature. Use of forced air warming devices has been effective at increasing body temperature. Be aware that shivering increases cardiac output, oxygen consumption, and carbon dioxide production, which might not be well tolerated by patients with fragile cardiac and pulmonary systems. Small doses of meperidine can reduce or stop shivering [Reference Apfelbaum, Silverstein and Chung5].