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

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The Postanesthesia Care Unit

At the conclusion of any procedure requiring anes-thesia, anesthetic agents are discontinued, monitors are disconnected, and the patient emerging from sedation or anesthesia is taken to the PACU.

THE POSTANESTHESIA CARE UNIT

 

At the conclusion of any procedure requiring anes-thesia, anesthetic agents are discontinued, monitors are disconnected, and the patient emerging from sedation or anesthesia is taken to the PACU. Fol-lowing general anesthesia, if an endotracheal tube or laryngeal mask airway (LMA) was utilized, and if ventilation is judged adequate, the endotracheal tube or LMA is usually removed prior to transport. Patients are also routinely observed in the PACU following regional anesthesia and monitored anes-thesia care (local anesthesia with sedation). Most procedure guidelines require that a patient be admit-ted to the PACU following any type of anesthesia, except by specific order of the attending anesthesiol-ogist. After a brief verbal (and in some cases written) “hand off ” re port to the PACU nurse, the patient is left in the PACU until the major effects of anesthesia have worn off. This period is characterized by a rela-tively high incidence of potentially life-threatening respiratory and circulatory complications.

 

The delivery of anesthesia services in areas remote from the main operating room, such as endoscopy, interventional radiology, and magnetic resonance imaging suites is increasingly common. Patients recovering from anesthesia delivered in these areas must receive the same standard of care as patients recovering from anesthesia received in the main operating room. Some institutions have devel-oped “satellite” PACUs to serve each of these remote areas individually, and others have combined their procedural areas into one centralized procedural suite served by a single PACU.

Design

 

The PACU should be located near the operat-ing rooms and off-site invasive procedure areas. A central location in the operating room area itself is desirable, as it ensures that the patient can be rushed back to surgery, if needed, or that members of the operating room team can quickly respond to urgent or emergent patient care issues. Proximity to radio-graphic, laboratory, and other intensive care facilities on the same floor is also advantageous. The transfer of critically ill patients in elevators or through long corridors can jeopardize their care because urgent problems may arise along the way.

 

An open-ward design facilitates observation of multiple patients simultaneously. However, an appropriate number of individually enclosed patient care spaces is required for patients needing isolation for infection control. A ratio of 1.5 PACU beds per operating room is customary, although this num-ber will vary depending on the respective operating room suite’s case volume, variety of surgical proce-dures, and patient acuity. Each patient space should be well-lighted and large enough to allow easy access to patients in spite of poles for intravenous infusion pumps, a ventilator, or radiographic equipment; construction guidelines dictate a minimum of 7 ft between beds and 120 sq ft/patient. Multiple electri-cal outlets, including at least one with backup emer-gency power, and at least one outlet each for oxygen and suction, should be present at each bed space.

 

Equipment

 

Many PACU incidents leading to serious morbidity or mortality are related to inadequate monitoring.Pulse oximetry (Spo2), electrocardiogram (ECG), and automated noninvasive blood pressure (NIBP)monitors are mandatory for each space. Although ECG, Spo2, and NIBP must be utilized for every patient in the initial phase of recovery from anes-thesia (phase 1 care), decreased monitoring may be adequate thereafter. Appropriate equipment must be available for those patients requiring invasive arte-rial, central venous, pulmonary artery, or intracranial pressure monitoring. Capnography is useful for intu-bated patients and is increasingly employed for extu-bated patients as well. Temperature-sensitive strips may be used to measure temperature in the PACU but are not sufficiently accurate to document the results of treatment for hypothermia or hyperther-mia; mercury or electronic thermometers must be used if an abnormality in temperature is suspected.

 

Forced-air warming device, heating lamp, and/or a warming/cooling blanket should be available.

The PACU must have its own supplies of basic and emergency equipment, separate from that of the operating room, based on the needs of the patient population. This includes airway equipment and supplies, such as oxygen cannulas, a selection of masks, oral and nasal airways, laryngoscopes, endo-tracheal tubes, LMAs, a cricothyrotomy kit, and self-inflating bags for ventilation. A readily available supply of catheters for vascular cannulation (venous, arterial, central venous) is mandatory. A defibrilla-tion device with transcutaneous pacing capabilities, and an emergency cart with drugs and supplies for advanced life support  and infusion pumps, must be present and periodically inspected. Transvenous pacing catheters; pulse generators; and tracheostomy, chest tube, and vascular cut-down trays are typically present, depending on the surgi-cal patient population.

Respiratory therapy equipment for aerosol bronchodilator treatments, continuous positive air-way pressure (CPAP), and ventilators should be in close proximity to the recovery room. Immediate availability of a bronchoscope is desirable.

 

Staffing

 

Inadequate staffing is often cited as a major contrib-uting factor in PACU mishaps. The PACU should be staffed by nurses specifically trained in the care of adult and/or pediatric patients emerging from anesthesia. They should have expertise in airway management and advanced cardiac life support, as well as problems commonly encountered in surgical patients relating to wound care, drainage catheters, and postoperative bleeding.

 

Patients in the PACU should be under the medi-cal direction of an anesthesiologist, who must be immediately available to respond to urgent or emer-gent patient care problems. High-volume tertiary care surgical institutions often have an anesthesiologist assigned full time to the PACU. The management ofthe patient in the PACU should reflect a coordinated effort involving anesthesiologists, surgeons, nurses, respiratory therapists, and appropriate consultants. The anesthesia team emphasizes management of analgesia, airway, cardiac, pulmonary, and metabolic problems, whereas the surgical team generally man-ages any problems directly related to the surgical procedure itself. Based on the assumptions that the average PACU stay is 1 hr and that the average inpa-tient procedure lasts 2–3 hr, a ratio of one recovery nurse for two patients is generally satisfactory. How-ever, staffing for nursing care should be tailored to the unique caseload requirements of each facility. If the operating room schedule regularly includes pedi-atric patients or frequent short procedures, a ratio of one nurse to one patient is often needed. A charge nurse should be assigned to ensure optimal staffing at all times, including the appropriate response to urgent or emergent patient care problems.

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