Postanesthesia Recovery
Each patient recovering from an anesthetic has circumstances that require an individualized problem-oriented approach (Fowler MA, Spiess BD. Postanesthesia recovery. In: Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Ortega R, Stock MC, eds. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins; 2013:1553–1579). Dissemination of anesthesia services beyond the perisurgical arena has brought changes and greater demands on recovery units. The American Society of Anesthesiologists has approved Standards for Postanesthesia Care.
I. Value and Economics of the Postanesthesia Care Unit
In the postanesthesia care unit (PACU), resources are efficiently used by having trained staff who routinely care for postsurgical patients, thereby recognizing and preventing complications and by having physicians institute appropriate and timely therapies. Routine testing and therapies may unnecessarily add to staffing resources required per patient without widespread demonstrated benefit to patient care.
Communication is perhaps the least expensive tool in medicine and the one that is most universally proven to be involved in human error events.
Having patients bypass the PACU creates a savings opportunity only if paid nursing hours are reduced or if more surgical cases are covered with the same hours.
II. Levels of Postoperative/Postanesthesia Care
Using a less intensive postanesthesia setting for selected patients may reduce costs for a surgical procedure and allow
the facility to divert scarce PACU resources to patients with greater needs.
Creation of separate PACUs for inpatients, ambulatory patients, and offsite patients is one possible way to streamline PACU care for appropriately triaged patients. Phase I recovery would be reserved for more intense recovery and would require more one-on-one care for patients. Phase II recovery would be less intensive and would be appropriate for patients after less invasive procedures requiring less nursing attention while recovering.
III. Postanesthetic Triage
Postanesthetic triage should be based on clinical condition, length and type of procedure and anesthetic, and potential for complications that require intervention.
An individual patient undergoing a specific procedure or anesthetic should receive the same appropriate level of postoperative care whether the procedure is performed in a hospital operating room, ambulatory surgical center, endoscopy room, invasive radiology suite, or outpatient office.
After superficial procedures using local infiltration, minor blocks, or sedation, patients can almost always recover with less intensive monitoring and coverage (bypass phase I recovery to phase II).
IV. Safety in the Postanesthesia Care Unit
The PACU medical director must ensure that the PACU environment is as safe as possible for both patients and staff.
Observance of procedures for hand washing, sterility, and infection control should be strictly enforced.
Compulsive documentation and clear delineation of responsibility protect staff against unnecessary medicolegal exposure.
V. Admission to the Postanesthesia Care Unit
Every patient admitted to a PACU should have his or her heart rate, rhythm, systemic blood pressure, airway patency, peripheral oxygen saturation, ventilatory rate and character, and level of pain recorded and periodically monitored. Assessment with periodic recording every 5 minutes for the first 15 minutes and every 15 minutes thereafter is a minimum.
Documenting temperature, level of consciousness, mental status, neuromuscular function, hydration status, and degree of nausea on admission and discharge and more frequently if appropriate are also minimum standards of care.
Every patient should be continuously monitored with a pulse oximeter and at least a single-lead electrocardiogram. Capnography is necessary for patients receiving mechanical ventilation and those at risk for compromised ventilatory function.
Anesthesiology personnel should manage the patient until a PACU nurse secures admission vital signs and attaches appropriate monitors. Care should be transferred with a complete report to the nursing staff (Table 54-1).
VI. Postoperative Pain Management
Relief of surgical pain with minimal side effects is a major goal during PACU care and is a top priority for patients.
In addition to improving comfort, analgesia reduces sympathetic nervous system response, avoiding hypertension, tachycardia, and dysrhythmias. In hypovolemic patients, the sympathetic nervous system activity may well mask relative hypovolemia.
Administration of analgesics may precipitate hypotension in an apparently stable patient, especially if direct or histamine-induced vasodilation occurs. Before giving analgesics that might precipitate or accentuate hypotension, it is important to carefully assess a tachycardic patient with low or normal blood pressure who complains of pain.
The best measure of analgesia is the patient’s perception. Heart rate, respiratory rate and depth, sweating, and nausea and vomiting may be signs of pain, but their absence or presence is not in itself reliable as a measure of the presence of pain.
Surgical pain can be effectively treated with intravenous (IV) opioids as part of a planned analgesic continuum that begins before the induction of surgical anesthesia and continues throughout the postoperative course.
Short-acting opioids are useful to expedite discharge and minimize nausea in ambulatory settings, although the duration of analgesia can be a problem. Other analgesic modalities provide pain relief in and beyond the PACU.
IV opioid loading in the PACU is important for smooth transition to IV patient-controlled analgesia.
Injection of opioids into the epidural or subarachnoid space during anesthesia or in the PACU yields prolonged postoperative analgesia in selected patients. Nausea and
pruritus are troubling side effects, and immediate or delayed ventilatory depression may occur related to vascular uptake and cephalad spread in cerebrospinal fluid. Nausea should resolve with antiemetics, and pruritus and ventilatory depression often respond to naloxone infusion.
Placement of long-acting regional analgesic blocks reduces pain, controls sympathetic nervous system activity, and often improves ventilation.
After shoulder procedures, interscalene block yields almost complete pain relief with only moderate inconvenience from motor impairment. Paralysis of the ipsilateral diaphragm may impair postoperative ventilation in patients with marginal reserve, although the impact is small in most patients.
Suprascapular nerve block might be an alternative to avoid this potentially serious side effect.
Caudal analgesia is effective in children after inguinal or genital procedures. Infiltration of local anesthetic into joints, soft tissues, or incisions decreases the intensity of pain.
Table 54-1 Components of A Postanesthesia Care Unit Admission Report | |||||
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VIII. Postoperative Evaluation
The Centers for Medicare and Medicaid Services has instituted compliance polices that include postanesthesia follow-up (written documentation no later than 48 hours after the procedure) (Table 54-3).
IX. Cardiovascular Complications
The first sign of myocardial ischemia may well be hypotension, and the most common sign of myocardial ischemia is tachycardia. Early intervention with nitrates, opioids, β-blockers, and even anticoagulants may save lives. A cardiologist should be involved to gain immediate and timely access to the cardiac catheterization laboratory or for anxiolytic drug therapy.
Congestive heart failure is epidemic in our ever-aging population. Echocardiography allows rapid viewing of myocardial contractility, regional wall motion, volume status, and valvular dysfunction.
