Patient Care in the PACU Presenters: Cindy Carnegie, Nurse Clinician, Acute Pain Service, UH Ruth Miles, Nursing Coo

1. Patient Care in the PACUPresenters: Cindy Carnegie, Nurse Clinician, Acute Pain Service, UHRuth Miles, Nursing Coordinator, PACU, Surgical Prep, and Preadmission Clinic, UH

2. Post Anesthetic Care Unit (PACU) The PACU is a division of the Department of Anesthesia and Perioperative Medicine Short-term intensive care unit Self sufficient unit with staff experienced in handling a wide range of emergencies and crises

3. Surgery’s Stressors Surgical tissue injury Anesthetic agents Muscle relaxants Preexisting health issues influence body response

4. Anesthesiologists Manage certain aspects of patient’s physiology During recovery the patient’s body resume control of these functions In this transition, some patients need medical assistance to ensure a safe transition

5. PACU Nurses Monitor for: Potentially life threatening complications Inevitable discomforts such as pain and postoperative nausea and vomiting

6. Responsibilities of the Anesthesiologist and PACU Nurses The anesthesiologist accompanies the patient during transport to the PACU. At the PACU, the anesthesiologist reassesses the status of the patient. The anesthesiologist then reports the patient's relevant medical history and gives the post anesthesia care orders to the PACU nurse. PACU nurses monitor the patient continually, provide direct care, and notify the anesthesiologist immediately of any problems. Once the patient meets discharge criteria, the patient is transported to the next stage of care

7. Care During Transport: Operating Room (OR) to PACU The anesthesiologist take direct responsibility for the patient status during transport Maintenance of airway is a critical component of care during this time During this short trip most patients become hypoxemic

8. PACU Admitting Report (from the Operating Room Nurse) OR Nurse gives a verbal report includes surgical diagnosis, procedure, and outcome Allergies Drains Dressings

9. The Anesthesiologist’s Report The attending Anesthesiologist checks and records the patient’s vital signs The Anesthesiologist gives the PACU nurse a verbal report This report helps the PACU nurse set individual patient care priorities for each patient

10. PACU Admitting Report(from the operative Anesthesiologist) Preoperative Essential history and physical exam data Mental status Communication disabilities

11. PACU Admitting Report (con’d) Intraoperative Type of anesthesia and muscle relaxation drugs used Course of surgery, any intraoperative events, any special intraoperative medications Complications, including losses or replacements of blood or fluids

12. PACU Admitting Report (con’d) Postoperative Medications Transfusions or fluid replacements needed Airway and ventilation requirements Complications to watch for (e.g. Lab work (blood work), chest x-ray, ECG) Direction regarding management of lines e.g. arterial lines

13. Recovery from Anesthesia The PACU team's aim is for patients to emerge gradually and safely from anesthesia.

14. Medical Complications During Recovery Respiratory depression or distress Blood temperature problems Postoperative nausea and vomiting Postoperative pain Blood gases abnormalities Cardiovascular problems Blood sugar abnormalities Postoperative agitation and delirium Delayed emergence bloobloo

15. Respiratory Complications Profile of patients at risk include: Male patient Older adult Long surgery Emergency surgery Diabetes or obesity

16. Hypoxemia Hypoxemia is an abnormally low concentration of oxygen in the blood (PaO2 <60 mm Hg)

17. Hypercapnia Hypercapnia is an abnormally high concentration of carbon dioxide in the blood (PaCO2 >45 mm Hg).

18. Causes of Hypoxemia and Hypercapnia in the PACU Pain Diaphragm strain Airway obstruction Lingering effects of anesthesia Incomplete reversal of muscle relaxants Pulmonary edema Mechanical constraints The heart

19. Upper Airway Obstruction: Intubated Patient On transfer to PACU: the placement and patency of their endotracheal tube is assessed Signs of obstruction are treated with oxygen and suctioning.

20. Extubation in PACU Prior assess patency and protection of airway ? Muscle relaxant reversal Spontaneous breathing Suction available If “deep” on extubation, position patient to protect airway (e.g. side lying)

21. Upper Airway Obstruction:No Endotracheal Tube Upper airway obstruction may result from: tongue flopping back into the oropharynx oropharyneal muscles may be loose and toneless r/t muscle relaxant use laryngospasm (spasm of the vocal cords) vocal cord paralysis and edema of the glottis compression e.g. neck hematoma or dressings

22. Hypothermia Profile of patient at risk include: Older patient Long surgery Open thoracic or open abdominal surgery Thyroid or adrenal deficiency Lean body

23. Postoperative Pain, Nausea and Vomiting Patients consider nausea, vomiting, and pain as the worst postoperative experiences Severe postoperative pain and/or nausea/emesis are detrimental to recovery

24. Postoperative Nausea and Vomiting (PONV) Profile of patients at risk include: Female patient Non-smoker Long surgery Nitrous oxide during surgery Opioids during or after surgery History of PONV History of motion sickness NOTE: there are many different causes of nausea. Assess each patient individually.

25. Postoperative Pain Pain affects: ventilation immune system (increasing infection) GI tract (decreased gastric emptying) endocrine system (altered hormone release causing metabolic disturbances) The stress/inflammatory response to pain puts the body into a prothrombotic (hypercoagulable) state increasing blood clotting risks

26. Pain is a nerve fiber response We now know that nerve fibers have the ability to adapt or are “neuroplastic.” So . . . If severe pain is not controlled, it may: negatively affect patient recovery lead to development of chronic pain

27. Types of Pain Nociceptive Pain: an innate protective physical response to injury. Injury activates pain sensing nerve fibers sending communication of such pain to the CNS > descriptors might include achy, throbbing pain Neuropathic Pain: damage to the nervous system itself related to disease or trauma > descriptors sound like electricity such as stabbing, burning, shooting pain

28. Medical Management of Pain Nociceptive pain responds well to opioids For Neuropathic pain management opioids are third line after: Tricyclic antidepressants and anticonvulsants e.g.,Pregabulin Topical Lidocaine and SNRIs (serotonin/norepinephrine reuptake inhibitors) e.g. Duloxetine