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UF Health University of Florida
Department of Anesthesiology College of Medicine
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Education Overview

Postoperative

PONV
Respiratory & Airway Problems
hypertension
Delayed Awakening
Other Specific Conditions
PACU Discharge

Postoperative Nausea and Vomiting – PONV

Risk Factors

  • Patient Factors
    • Female gender
    • History of PONV or motion sickness
    • Non-smoking status
    • Younger age
  • Anesthetic factors
    • Volatile anesthetics
    • Longer duration of anesthesia
    • Perioperative opioid use
    • Nitrous oxide use
  • Surgical factors
    • Abdominal procedures
    • Gynecological/breast surgery
    • ENT surgery
    • Strabismus surgery
    • Urologic surgery

Strategies to Reduce Baseline Risk

  • Avoidance of general anesthesia by the use of regional anesthesia
  • Use of propofol for induction and maintenance of anesthesia
  • Avoidance of nitrous oxide
  • Avoidance of volatile anesthetics
  • Minimization of intraoperative and postoperative opioids
  • Adequate hydration

Source: Consensus guidelines for the management of postoperative nausea and vomiting

Respiratory and Airway Problems

Common Causes of Respiratory Insufficiency in the PACU

Hypoventilation

  • Residual anesthesia
  • Residual muscle relaxant
  • Postop opioids
  • Splinting 2o to pain
  • Tight abdominal binder
  • Obstructive sleep apnea/obesity
  • Premature infants/neonates

Upper Airway Obstruction

  • Airway edema
  • Trauma
  • Vocal cord paralysis
  • Arytenoid dislocation
  • Secretions
  • Foreign body
  • Laryngospasm
  • Anxiety/Munchausen’s stridor

Hypoxemia

  • Atelectasis
  • Asthma/COPD exacerbation
  • CHF/fluid overload
  • Pulmonary embolism
  • ALI/ARDS
  • Aspiration
  • Pneumo/hemothorax pleural effusion
  • Diaphragmatic injury/paralysis
  • Pneumonia

Respiratory Insufficiency: Diagnosis & Management

  1. Assess Airway, Breathing, Circulation
  2. ↑ delivered FiO2, ↑ flow rate and consider non-rebreather or shovel mask
  3. Consider jaw thrust/chin lift, placement of oral/nasal airway
  4. Consider positive-pressure ventilation with bag-valve mask
  5. Consider intubation vs. noninvasive ventilation (CPAP/BiPAP)
  6. Review patient history, OR and postop course, fluid status, and medications administered
  7. Consider ABG, chest X-ray (rule out pneumothorax/pulmonary edema)

Treatment of Hypoventilation

Source: D. Keith Rose, Marsha M. Cohen, Dan F. Wigglesworth, Don P. DeBoer; Critical Respiratory Events in the Postanesthesia Care Unit: Patient, Surgical, and Anesthetic Factors. Anesthesiology 1994; 81:410–418 

Source: https://aneskey.com/management-and-discharge/

Hypertension

Common Causes of Hypertension in the PACU

  • Pain
  • Anxiety
  • Respiratory insufficiency (hypoxia, hypercarbia)
  • Hyperthermia/shivering
  • ↑ sympathetic activity
  • ↑ ICP
  • Essential hypertension/missed medications
  • Fluid overload
  • Endocrine disease (thyroid storm, pheochromocytoma)
  • Error in measurement (inappropriate cuff size, machine malfunction)

Treatment

  • Treat underlying cause, resume home antihypertensives
  • For initial treatment, consider:
    • Labetalol 5-40 mg IV bolus q 10 minutes
    • Hydralazine 2.5-20 mg IV bolus q 10-20 minutes
    • Lopressor 2.5-10 mg IV bolus

Source: https://aneskey.com/management-and-discharge/

Delayed Awakening

Causes of Delayed Awakening in PACU

Anesthesia related

  • Residual anesthetic
  • Residual muscle relaxant, pseudocholinesterase deficiency
  • Excessive narcotics

Metabolic

  • Hypothermia
  • Hypoxemia
  • Hypercarbia/hyponatremia/hypocalcemia/hypoglycemia
  • Renal/hepatic failure

Intracranial event

  • Stroke/cerebrovascular incident (CVA)
  • Seizure
  • Intracranial hypertension

Diagnosis

  • Perform complete neuro assessment (cranial, motor, & sensory nerves)
  • Review anesthetic record for drugs/doses
  • Check for residual muscle relaxant with train-of-four/tetany
  • Send ABG, serum sodium/calcium/glucose levels, check pt temp
  • Consider application of bispectral index/EEG
    • Low bispectral index may be suggestive of residual anesthetic
    • EEG can assess for seizure activity
  • Consider neurologic imaging to assess for stroke (noncontrast CT/MRI brain)
  • Consider pseudocholinesterase deficiency (family hx, pseudocholinesterase level, dibucaine number)

Treatment

  • Consider narcotic reversal if slow respiratory rate + pin point pupils
    • administer naloxone (0.04 mg IV q2min up to 0.2mg IV)
  • Consider benzo reversal with flumazenil (0.2 mg IV q2min up to 1 mg IV)
  • Reverse muscle relaxants, correct electrolyte abnl, rewarm pt as indicated

Other Specific Conditions

Hypovolemia

Diagnosis

Tachycardia, hypotension, low CVP/PCWP, respiratory variation in arterial waveform, IVC collapse/underfilled LV on echo

Treatment

Fluid resuscitation, assess for causes (ongoing bleeding, diuresis, high NG outout)

Bleeding

Diagnosis

Tachycardia, anemia, hypovolemia, sanguineous drain output

Treatment

Fluid resuscitation, blood transfusion, correct coagulopathy & thrombocytopenia, treat hyperthermia, consider return to OR

Sepsis

Diagnosis

Fever, leukocytosis, tachycardia, hypovolemia, lactic acidosis

Treatment

Fluid resuscitation, obtain blood/specific cultures, initiate broad-spectrum antibiotics

Myocardial Infarction/Ischemia

Diagnosis

12-lead ECG, TTE/TEE, cardiac enzymes, cardiology consult

Treatment

Cautious fluid resuscitation, aspirin, discuss with cardiologist & surgeon role of heparinization/cardiac cath/antiplatelet agents; consider inotropic/vasopressor/IABP support; may initiate diuresis/beta-blockade once BP stabilized

Arrhythmias

Diagnosis

12-lead ECG, cardiac enzymes, check electrolytes, ABG

Treatment

Treat the cause, follow ACLS protocol

  • Tachyarrhythmia: Electrical/chemical cardioversion, correct electrolytes, cardiology consultation, maintenance antiarrhythmics
  • Bradyarrhythmia: Atropine/epinephrine/dopamine, transcutaneous transvenous pacing, cardiology consult

Drugs

Treatment

Stop the drug, administer antagonist agent (e.g., naloxone for morphine)

Pulmonary Embolism

Diagnosis

  • ECG – sinus tach/S1Q3T3; ultrasound of lower ext; D-dimer not helpful
  • TTE/TEE – rule out central pulm embolism/assess RV dysfx
  • V/Q scan/CT chest pulm angiogram when stable

Treatment

  • Cautious fluid resuscitation, invasive monitoring, inotropes/pressors
  • Consider thromboembolectomy/catheter-directed thrombolysis/anticoagulation/IVC filter placement

Congestive Heart Failure

Diagnosis

  • Bibasilar crackles, frothy sputum on examination
  • Chest x-ray – cephalization of blood vessels, pulmonary edema, ↑ cardiac shadow
  • Invasive hemodynamic monitoring shows low cardiac output, ↑ filling pressures

Treatment

Supplemental O2, diuresis, digoxin/inotropic support

Anaphylaxis

Diagnosis

  • Tachycardia, vasodilatory shock (low SVR, high cardiac output)
  • Check serum tryptase & eosinophil count, consult allergy

Treatment

Remove causative agent, fluid resuscitation, diphenhydramine, steroids, epinephrine

Aspiration

Diagnosis

Chest x-ray may reveal foreign body, infiltrates, atelectasis or collapse

Treatment

  • Supportive care for small aspirations (no respiratory compromise)
  • Large aspirations: Rapid sequence intubation, gastric decompression, mechanical ventilation with high PEEP, bronchoscopy to remove large foreign bodies; prophylactic antibiotics & steroids are ineffective; bronchoalveolar lavage & routine suctioning should not be performed
  • Prevent recurrence: Elevate head of bed, avoid sedation, place NG tube

Upper Airway Obstruction/Stridor

Causes

Airway edema/trauma, vocal cord paralysis, arytenoid dislocation, secretions, foreign body

Treatment

  • Racemic epinephrine, dexamethasone, humidifies air, heliox
  • Treat secretions with suctioning & admin of glycopyrrolate (0.2 mg IV)
  • Severe edema/trauma may necessitate reintubation
  • Obtain ENT consult for vocal cord paralysis/arytenoid dislocation/removal of foreign body

Pneumothorax/Hemothorax/Pleural Effusion

Diagnosis

Chest x-ray diagnostic most of the time

Treatment

  • Needle decompression of chest (2nd intercostal space in midclavicular line), chest tube decompression (also see Chapter 11, Anesthesia Procedures)
  • Exploratory thoracotomy for large hemothorax/ongoing bleeding

PACU Discharge Criteria

Phase 1: Starts with pt entering PACU from OR till criteria are met for transfer to phase 2 in PACU/hospital room/ICU (Note: patients are not discharged home from phase 1)

Phase 2: Starts with completion of phase 1, ends with patient discharge to home

Common Discharge Issues (Anesthesiology 2002;96:742–752)

  • Passing of urine is not a mandatory requirement
  • Ability to drink and retain fluids is not mandatory
  • There is no minimum PACU stay period
  • Escort is needed if patient received any sedation

Source: https://aneskey.com/management-and-discharge/