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The%20Post%20Anesthesia%20Care%20Unit

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Title: The Post Anesthesia Care Unit Author: School of Allied Health Last modified by: Jumanah Created Date: 4/26/1996 1:08:06 PM Document presentation format – PowerPoint PPT presentation

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Title: The%20Post%20Anesthesia%20Care%20Unit


1

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Lecture Title Acute Pain Management
Lecture date
2
Lecture Objectives..
  • Students at the end of the lecture will be able
    to
  • Learn a common approach to emergency medical
    problems encountered in the postoperative period.
  • Study post-operative respiratory and hemodynamic
    problems and understand how to manage these
    problems.
  • Learn about the predisposing factors,
    differential diagnosis and management of PONV.
  • Understand the causes and treatments of
    post-operative agitation and delirium.
  • Learn about the causes of delayed emergence and
    know how to deal with this problem.
  • Learn about different approaches of
    post-Operative pain management

3
Postoperative care- Post Anesthesia Care
UnitPACU
4
PACU
  • Design should match function
  • Location
  • Close to the OR.
  • Access to x-ray, blood bank clinical labs.
  • Monitoring equipment
  • Emergency equipment
  • Personnel

5
Admission to PACU
  • Steps
  • Coordinate prior to arrival,
  • Assess airway,
  • Administer oxygen,
  • Apply monitors,
  • Obtain vital signs,
  • Receive report from anesthesia personnel.

6
PACU - ASA Standards
  • Standard I
  • All patients should receive appropriate care
  • Standard II
  • All patients will be accompanied by one of
    anesthesia team
  • Standard III
  • The patient will be reevaluated report given to
    the nurse
  • Standard IV
  • The patient shall be continually monitored in the
    PACU
  • Standard V
  • A physician will signing for the patient out of
    the PACU

7
Patient Care in the PACU
  • Admission
  • Apply oxygen and monitor
  • Receive report
  • Monitor Observe Manage
  • ? To Achieve
  • Cardiovascular stability
  • Respiratory stability
  • Pain control
  • Discharge from PACU

8
Monitoring in the PACU
  • Baseline vital signs.
  • Respiration
  • RR/min, Rythm
  • Pulse oximetry
  • Circulation
  • PR/min Blood pressure
  • ECG
  • Level of consciousness
  • Pain scores

9
Initial Assessment
  1. Color
  2. Respiration
  3. Circulation
  4. Consciousness
  5. Activity

10
Aldrete Score
Score Activity Respiration Circulation Consciousness Oxygen Saturation
2 Moves all extremities Breaths deeply and coughs freely. BP 20 mm of preanesth. level Fully awake Spo2 gt 92 on room air
1 Moves 2 extremities Dyspneic, or shallow breathing BP 20-50 mm of preanesth. level Arousable on calling Spo2 gt90 With suppl. O2
0 Unable to move Apneic BP 50 mm of preanesth. level Not responding Spo2 lt92 With suppl. O2
11
Common PACU Problems
  • Airway obstruction
  • Hypoxemia
  • Hypoventilation
  • Hypotension
  • Hypertension
  • Cardiac dysrhythmias
  • Hypothermia
  • Bleeding
  • Agitation
  • Delayed recovery
  • PONV
  • Pain
  • Oliguria

12
1. Airway Obstruction
  • Most common tongue fall back
  • ? posterior pharynx
  • May be foreign body
  • Inadequate relaxant reversal
  • Residual anesthesia

13
Management of Airway Obstruction
  • Patients stimulation,
  • Suction,
  • Oral Airway,
  • Nasal Airway,
  • Others
  • Tracheal intubation
  • Cricothyroidotomy
  • Tracheotomy

14
2. Hypoventilation
  • Residual anesthesia
  • Narcotics
  • Inhalation agent
  • Muscle Relaxant
  • Post oper - Analgesia
  • Intravenous
  • Epidural

15
Treatment of Hypoventilation
  • Close observation,
  • Assess the problem,
  • Treatment of the cause
  • Reverse (or Antidote)
  • Muscle relaxant ? Neostigmine
  • Opioids ? Naloxone
  • Midazolam ? Anexate

16
3. Hypertension
  • Common causes e.g.
  • Pain
  • Full Bladder
  • Hypertensive patients
  • Fluid overload
  • Excessive use of vasopressors

17
Treatment of Hypertension
  • Effective pain control
  • Sedation
  • Anti-hypertensives
  • Beta blockers
  • Alpha blockers
  • Hydralazine (Apresoline)
  • Calcium channel blockers

18
4. Hypotension
  • Decreased venous return
  • Hypovolemia,
  • ? fluid intake
  • ? losses
  • Bleeding
  • Sympathectomy,
  • 3rd space loss,
  • Left ventricular dysfunction

19
Treatment of Hypotension
  • Initially treat with fluid bolus,
  • Vasopressors,
  • Correction of the cause

20
5. Dysrhythmias
  • Secondary to
  • Hypoxemia
  • Hypercarbia
  • Hypothermia
  • Acidosis
  • Catecholamines
  • Electrolyte abnormalities.

21
Treatment of Dysrhythmia
  • Identify and treat the cause,
  • Assure oxygenation,
  • Pharmacological

22
6. Urine Output
  • Oliguria
  • Hypovolemia,
  • Surgical trauma,
  • Impaired renal function,
  • Mechanical blocking of catheter.
  • Treatment
  • Assess catheter patency
  • Fluid bolus
  • Diuretics e.g. Lasix

23
7. Post op Bleeding
  • Causes
  • Usually Surgical Problem,
  • Coagulopathy,
  • Drug induced

24
Treatment of Post op Bleeding
  • Treatment
  • Start i.v. lines ? push fluids
  • Blood sample,
  • CBC,
  • Cross matching,
  • Coagulopathy
  • Notify the surgeon,
  • Correction of the cause

25
8. Hypothermia
  • Most of patients will arrive cold
  • Treatment
  • Get baseline temperature
  • Actively rewarm
  • Administer oxygen if shivering
  • Take care for
  • Pediatric,
  • Geriatric.

26
9. Altered Mental Status
  • Reaction to drugs?
  • Drugs e.g. sedatives, anticholinergics
  • Intoxication / Drug abusers
  • Pain
  • Full bladder
  • Hypoventilation
  • Low COP
  • CVA

27
Treatment of Altered Mental Status
  • Reassurances,
  • Always protect the patient,
  • Evaluate the cause,
  • Treatment of symptoms,
  • Sedatives / Opioids if necessary.

28
10. Delayed Recovery
  • Systematic evaluation
  • Pre-op status
  • Intraoperative events
  • Ventilation
  • Response to Stimulation
  • Cardiovascular status

29
Delayed Recovery
  • The most common cause
  • Residual anesthesia ? Consider reversal
  • Hypothermia,
  • Metabolic e.g. diabetic coma,
  • Underlying psychiatric problem
  • CVA

30
11. Postoperative Nausea Vomiting PONV
  • Risk factors
  • Type duration of surgery,
  • Type of anesthesia,
  • Drugs,
  • Hormone levels,
  • Medical problems,
  • Autonomic involvement.

31
Prevention of PONV
  • NPO status
  • Dexamothasone,
  • Droperidol,
  • Metoclopramide,
  • H2 blockers,
  • Ondansetron,
  • Acupuncture

32
12. Postoperative Pain
33
12. Postoperative Pain
  • Causes
  • Incisional Skin and subcutaneous tissue
  • Laparoscopy Insuflation of Co2
  • Others
  • Deep cutting, coagulation, trauma
  • Positional nerve compression, traction bed
    sore.
  • IV site needle trauma,
    extravasation, venous irritation
  • Tubes drains, nasogastric tube,
    ETT
  • Surgical complication of surgery
  • Others cast, dressing too tight,
    urinary retention

34
PAIN MEASUREMENTS
Subjective Objective
Uni-Dimensional Multidimentional Behavioral. Physiological. Neuro-endocrinal. Algometry.
VRS, VAS NRS. Facial expression. McGill P Q, Pain Inventory. Behavioral. Physiological. Neuro-endocrinal. Algometry.
ACUTE PAIN Chronic Pain Both
35
Pain Scores
Visual Analogue Scale (VAS) 0
10
Numeric Rating Scale (NRS)
36
Verbal scale
Wong-Baker Faces Scale
37
Pharmaco - Therapy
ACUTE POSTOPERATIVE MANAGEMENT TOOLS
Regional Techniques
  • Local infiltration
  • Wound perfusion
  • Intra-abdominal inj. of LA/Analg.
  • Intercostal Interpleural
  • Paravertebral
  • USG-RA e.g. TAP
  • Neuraxial
  • Epidural
  • Thoracic
  • Lumbar
  • Spinal
  • Single shot
  • CSA
  • CSE
  • Non Opioid Analgesics
  • NSAADs
  • Analgesic /Antipyretic
  • Analgesic/Anti-inflam/Antipyretic
  • NSAIDs
  • Non-selective COX inhibitors
  • Selective COX-2 inhibitors
  • Opioids
  • Weak Opioids.
  • Strong Opioids.
  • Mixed agonist-antagonists
  • Adjuvants
  • ?-2 Agonists
  • LA
  • SP inhibitors
  • NMDA inhibitors
  • Anticonvulsant / Antidepressants
  • Calcitonin
  • Relaxants

38
WHO Ladder Updated
WHO IV Interventional
Severe pain (7-10)
WHO III Strong opioids
Adjuvant
Pain Persists or Increases
Moderate pain (4-6)
WHO class II Weak opioids
Adjuvant
  • By the mouth
  • By the clock
  • By the ladder

Mild pain (0-3)
WHO class I NSAIDs
Adjuvant
39
WHO (I) Non Opioid Analgesics
  • Non Opioid Analgesics
  • NSAADs
  • Analgesic / Anti-inflam / Antipyretic /
    Anticoagulant
  • ASA
  • Analgesic /Antipyretic
  • Paracetamol
  • NSAIDs
  • Non-selective COX inhibitors
  • Diclofenac Ketoprofen
  • Selective COX-2 inhibitors
  • Celecoxib Rofecoxib

Severe pain (7-10)
40
Scientific Evidence NON OPIOID ANALGESICS
  1. Paracetamol
  2. is an effective analgesic for acute pain the
    incidence of adverse effects comparable to
    placebo (Level I Cochrane Review).
  3. Paracetamol / NSAIDs given in addition to PCA
    Opioids ? ? Opioid consumption (Level I).
  4. NSAIDs
  5. are effective in the treatment of acute
    postoperative (Level I ).
  6. With careful patient selection and monitoring,
    the incidence of renal impairment is low (Level I
    Cochrane Review).
  7. NSAIDs Paracetamol improve analgesia compared
    with paracetamol alone (Level I).

Acute Pain Management - Scientific Evidence -
AAGBI Guidelines 2010
41
WHO Ladder II - Weak Opioids
  • Tramadol
  • Tramadol Morphine
  • Parenteral 1 10 Oral 1 5
  • Dose 200 400 mg/d
  • Codeine
  • Metabolized to morphine.
  • Codeine Morphine 1 10
  • Dextro-propoxyphene
  • Methadone Derivative
  • Prolongation of Q-T interval.

Severe pain (7-10)
42
Scientific Evidence WEAK OPIOIDS
  • Tramadol
  • has a lower risk of respiratory depression
    impairs GIT motor function lt other opioids
  • (Level II).
  • is an effective treatment for neuropathic pain
  • (Level I Cochrane Review).
  • Dextropropoxyphene
  • has low analgesic efficacy
  • (Level I Cochrane Review).

Acute Pain Management - Scientific Evidence -
AAGBI Guidelines 2010
43
WHO Ladder III - Strong Opioids
  1. Morphine
  2. Sedation
  3. PONV
  4. Respiratory Depression
  5. Fentanyl
  6. Rapid action, Short duration.
  7. Fentanyl Mophine (110)
  8. Pethidene
  9. Active metabolite ? t½ .
  10. Prolongs Q-T interval.
  11. Pethidine Mophine (110)
  12. Hydromorphone
  13. Powerful, rapidly acting.
  14. Release is in distal gut.
  15. Hydromorphone Morphine 1 5

Severe pain (7-10)
44
WHO Ladder IV Regional Anesthetic Techniques
  • Local infiltration
  • Wound perfusion
  • Intra-abdominal LA
  • Intercostal
  • Interpleural
  • Paravertebral
  • USG - RA e.g. TAP
  • Neuraxial
  • Epidural
  • Thoracic
  • Lumbar
  • Spinal
  • Single shot
  • CSA
  • CSE

45
Neuraxial (Spinal / Epidural)(LA / Opioids /
others)
  • Advantages
  • Provide prolonged effective analgesia
  • Side effects
  • Respiratory depression.
  • N/V.
  • Pruritis.
  • Urinary retention.

46
WHO Algorithm for Management of Pain
  • Multidisciplinary
  • Adjuvant therapy.
  • Psychotherapy.
  • Physioltherapy.
  • Causal diag. ttt.

Neuraxial LA Opioids
WHO III Strong opioids
Plexus block
Paravertebral / PNB
WHO class II Weak opioids
Non-pharmacological
LA infiltration
WHO class I NSAIDs
47
Management Algorithm for Postoperative Pain
Diagnosis
Preventive / Preemptive
Procedure Specific Pain manag.
Pain Assessment
ttt of Pain and Co morbidities
1ry Treatment
Supportive Treatment
Psychological ttt.
Pharmacotherapy
Physical / Rehab.
Interventional
48
PACU Discharge Criteria
  • Fully Awake,
  • Patent airway,
  • Good respiratory function,
  • Stable vital signs,
  • Patency of tubes, catheters, IVs
  • Pain free,
  • Reassurance of surgical site.

49
Postanesthesia Discharge Scoring System
Vital Signs (PR ABP) Activity PONV Pain Surgical Bleeding
2 Within 20 of preoperative baseline 2 Steady gait, no dizziness 2 Minimal treat with PO meds 2 Acceptable control per the patient controlled with PO meds 2 Minimal no dressing changes required
1 20-40 of preoperative baseline 1 Requires assistance 1 Moderate treat with IM medications 1 Not acceptable to the patient not controlled with PO meds 1 Moderate up to 2 dressing changes
0 gt40 of preoperative baseline 0 Unable to ambulate 0 Continues repeated treatment 0 Severe Uncontrolled pain 0 Severe more than 3 dressing changes
50
Reference book and the relevant page numbers..
51
Thank You ?
  • Dr.
  • Date
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