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Chapter: Clinical Anesthesiology: Perioperative & Critical Care Medicine: Postanesthesia Care

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Postanesthesia Care

Historically, emphasis on specialized nursing care during the immediate postoperative period was prompted by the realization that many early postop-erative deaths occurred immediately after anesthesia and surgery and that many of these deaths were preventable.

Postanesthesia Care

 

Historically, emphasis on specialized nursing care during the immediate postoperative period was prompted by the realization that many early postop-erative deaths occurred immediately after anesthe-sia and surgery and that many of these deaths were preventable. A nursing shortage in the United States following World War II, as well as the experience of providing surgical care to large numbers of battle casualties during the war, contributed to the post-war trend of centralization of immediate postopera-tive care in the form of recovery rooms, where one or more nurses could pay close attention to several acute postoperative patients at one time. Over the past two decades, the accelerating practice of car-ing for selected postoperative patients overnight in a postanesthesia care unit (PACU), or the equivalent, has been a response to increasingly complex surgi-cal procedures performed on higher-acuity patients, often in the setting of a shortage of surgical intensive care beds. The success of PACUs in decreasing post-operative morbidity and mortality has been a major influence on the evolution of modern surgical inten-sive care units.

 

Another recent transformation in postanesthe-sia care is related to the shift from inpatient to out-patient surgery. It is estimated that more than 70% of all surgical procedures in the United States are now performed on an outpatient basis. Two phases of recovery may be recognized for outpatient sur-gery. Phase 1 is the immediate intensive care level recovery that cares for patients during emergence and awakening from anesthesia and continues until standard PACU criteria are met (see Discharge Criteria below). Phase 2 is a lower-level care that ensures that the patient is ready to go home. “Fast-tracking” of selected outpatients may allow them to safely bypass phase 1 recovery and go directly to the phase 2 level of care.

 

In many institutions, the PACU also commonly functions as a more intensely monitored location for perioperative and chronic pain patients under-going procedures such as single-shot nerve blocks and placement of epidural and peripheral nerve catheters, and for patients undergoing other proce-dures such as central line placement, electroconvul-sive therapy, and elective cardioversion. The PACU must be appropriately staffed and equipped to routinely manage these patients and their potential procedure-related complications. For example, in areas where regional and epidural blocks are admin-istered, Intralipid ® should be stocked in anticipation of treating local anesthetic toxicity.

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