39. POST ANAESTHETIC CARE UNIT/RECOVERY

Recovery from anaesthesia is the time from the end of surgery to when the patient is alert and physiologically stable. The anaesthetist is responsible for the care of the patient while he or she are recovering from the effects of anaesthesia. For most patients, recovery from anaesthesia is uneventful however complications in the immediate postoperative period can be sudden and life-theatening. All patients should be nursed in a post anaesthetic care unit (PACU) or “recovery” before returning to a ward bed.

The PACU must be located close to the operating theatres so that the anaesthetist can quickly attend and be staffed by trained nursing staff.

All patients will benefit from supplemental oxygen.

Functions of PACU

The main functions of a PACU are to

monitor the patient’s vital signs more closely than is possible on the ward,

optimise the patient’s analgesia,

quickly detect and treat early complications after surgery and anaesthesia.

Transport

Patients should be transported from the operating theatre on their side by the anaesthetist. Regurgitation of gastric contents while the patient is supine is more likely to result in pulmonary aspiration. Giving oxygen though a facemask can prevent hypoxia.

Admission

The anaesthetist must “hand over” the patient to the nurse who will care for the patient in the PACU. The anaesthetist should tell the nurse about the patient’s pre-existing illnesses, the operation, the anaesthetic, the fluid balance and any intra-operative problems. The anaesthetist should inform the nurse of any postoperative orders including analgesia and intravenous fluid treatment.

Anaesthetists must not leave the patient until they are certain that the patient is stable. They should wait until the first set of observations is performed.

Monitoring

Close observation of the patient’s respiratory, cardiovascular and conscious state is most important.

Observations should be performed and recorded every five minutes.

Respiratory system and airway:           

rate, depth and character of respiration. Oxygen saturation monitoring if available.

Cardiovascular system:            

pulse rate and rhythm, blood pressure, bleeding (drain tubes, drainage bottles and dressings).

Central nervous system:  conscious state, sedation score, pain score.

Renal system: urine output.

Miscellaneous: temperature.

Standard Care

The patient may require management of the airway, pain, nausea and vomiting, temperature and circulation. Some patients may develop postoperative complications that will need immediate recognition and treatment. The incidence of complications varies but has been estimated to occur in approximately 5% of patients.

Airway: All patients will benefit from oxygen therapy. Respiratory complications are the most common complication in PACU. Patients may require suctioning of their airway. An obstructed airway must be made patent by performing a “jaw thust” (backward tilt of the head with anterior displacement of the mandible), inserting a nasopharyngeal or an oropharyngeal airway, manually assisting ventilation or by intubating the trachea.

Pain: All patients should be asked about the amount of pain they are experiencing and have the pain treated. Patients should not be returned to the ward until their pain is well controlled. Patients given opioids in recovery should remain in PACU for at least another 30 minutes.

Nausea and vomiting: 10 to 50% of patients will have postoperative nausea and vomiting. This will depend on the patient’s age, sex, anaesthetic and type of surgery. Antiemetics should be given. The anaesthetist must be careful to exclude other causes of nausea including hypotension and pain.

Discharge Criteria

Discharge criteria. The patient should have a stable circulation, patent airway and adequate respiratory function, be conscious, have well controlled pain (pain score less than or equal to 3) and not be hypothermic. Nausea and vomiting should be treated.