臨床麻醉學-麻醉后監(jiān)測治療室

Post-anesthesiacareunit(PACU)

1MaincontentsandkeypointsSectionI:Emergence(Why)SectionII:MonitoringandcareinPACU(What)SectionIII:Dischargecriteria(When)SectionIV:EquipmentandfacultyforPACU(How)2

Emergencereferstothedurationfromceases

ofanestheticadministration

todisappearingofanestheticeffectsPACUisdesignedandstaffedtomonitorandcare

forpatientsinemergence

1.1DefinitionSectionIEmergence3ReductionofanesthesiadepthRecoveryofspontaneousrespirationRecoveryofairwayreflectsRecoveryofconsciousnessSectionI-Emergence1.2Fourphasesofemergence41.3OurjobsinthePACUSectionI-EmergencePatientsadmissionPatientsrecoveryPatientsdeliveryMonitoringDealwithcomplicationsExtubationDischargecriteriaHandoverInformationInformationtransmitting51.4InformationatthetimeofadmissionPatient'sname,age,bodyweightandwardnumberPreoperativecoexistingmedicaldiseasesanddrugtherapySurgicalprocedure,intraoperativetreatmentAnesthesiatypeIntraoperativevolumereplacement,bloodloss,urineoutputSpecialconditions:difficultintubation,shock,fullstomachAcaseSectionI-Emergence6Female,60y,60kgWithhypertentionPartialhepatectomyBloodloss1500ml1.5CriticalcriteriaandcautionruleinPACUThewarningboardshouldbehungwhencriticalpatientsweredeliveredintoPACU1.ASAscoreover3grades2.Over80yearsold3.Difficultairwayoremergencyairway4.Bloodlossover2000ml5.ReceivedCPCR6.Withirreversiblehypoxemia7.NeedkeepingtheendotrachealcathetersafteroperationSectionI-Emergence7SectionIIMonitoringandcare

Circulationsystem:ECG,HR,BP,SPO2,Urinevolume

Respiratorysystem:Frequency,extent,tidalvolume,airwaypressure,bloodgasanalysis,protectiveresponseResidualneuromuscularblockageConsciousnessTemperatureDrainageamount2.1Monitoringandobservation8HypoventilationAirwayobstructionHypoxiaCardiovascularinstabilityDeliriumHypothermiaandshiveringPostoperativenauseaandvomiting(PONV)SectionII-monitoringandcareinPACU2.2Managementofcomplications918000cases(24%)PONV(9.8%)Airwaysupport(6.8%)Hypotention(2.7%)Manifestation:SpO2<95%PaCO2>45mmHgTV/FCause:ventilatoryresponsetoCO2(MV/CO2)

Residualneuromuscularblockade

Primarypulmonarydisease,bindingManagement:Respiratorysupport,AntagonistSectionII:MonitorandcareinPACU2.2.1Hypoventilation102.2.2AirwayobstructionUpperairwayobstructionTonguecollapse:snore(jawthrustmaneuver)Accumulationofsecretion:rales(suction)Laryngealorthroatobstruction（maskventilation/intubation）Airwayedema:commoninchildren(corticoid)Lowerairwayobstruction

secretions(suctionandrelievingspasm)SectionII:MonitorandcareinPACU112.2.3HypoxemiaDiagnosisDeterminedbyarterialbloodgasanalysis

PaO2<60mmHg,withorwithouthypercapniaClinicalsigns

Cyanosisorflushingface

Dyspnea:lowtidalvolume,fastorslowrespirationrate

Lungauscultation:moistrales,wheezes,phlegmrales

SectionII:MonitorandcareinPACU12Commoncause

Alveolarhypoventilation

(residualeffectsofanestheticsand/orneuromuscularblockingdrugs)

Atelectasis(causeoflungshunting)(positiveairwaypressure)

Inhalationofgastriccontents(lavage)SectionII:MonitorandcareinPACU2.2.3HypoxemiaPulmonaryedema(fluidoverload,congestiveheartfailure

postobstructivepulmonaryedema)13SectionII:MonitorandcareinPACU2.2.3HypoxemiaTreatmentKeeptheairwayopenBesuretheabsenceofresidualeffectsIncreasetheinspiratoryoxygenconcentrationChangetheassistedbreathingmode(SIMV/CPAP/PEEP)DiuresisReintubationtothepatientsbeenextubated142.2.4Hypotension

Appearance:SBP<90mmHg

Cause:Intravasuclarvolumedepletion

(surgicalbleeding,bowelpreparation,

persistentfluidloss)

Decreasedcardiacoutput(myocardialischemia,cardiac

dysrhythmias,drugsinduced)

Management:FluidreplacementCardiovascularactivatorsSectionII:MonitorandcareinPACU152.2.5HypertensionAppearance:SBP>140mmHg

Cause:PreoperativehypertensionPain,hypoxemia,hypercarpnia,drugrebound

Surgicalprocedure(intracranialoperations)Management:SedationandanalgesiaPharmacologicbloodpressurecontrol(vasodilator)SectionII:MonitorandcareinPACU162.2.6ArrhythmiaTachycardia:Causedbypain,hypovolemiaorhypoxemia

Bradycardia:Causedbyhypothermia,hypoxemiaordrugs

Ventriculararrhythmia:Causedbyhypoxemia,electrolyteimbalance,acidosis,orunderlyingcardiacpathology

Treatment:IdentifyingandcorrectingunderlyingcauseDrugs(?-blocker,atropine,lidocaine)DefibrillationSectionII:MonitorandcareinPACU17Perioperativecardiacdysrhythmiasarefrequentlytransientandmultifactorial.Reversiblecausesofcardiacdysrhythmiasintheperioperativeperiodincludehypoxemia,hypoventilationandassociatedhypercapnia,endogenousorexogenouscatecholamines,electrolyteabnormalities,acidemia,fluidoverload,anemia,andsubstancewithdrawal.Theurgencyoftreatmentofacardiacdysrhythmiadependsonthephysiologicconsequencesofthedysrhythmia,principallyhypotensionorcardiacischemiaorboth.2.2.7PostoperativenauseaandvomitingDelayeddischargefromPACUUnanticipatedhospitaladmissionIncreasedincidenceofpulmonaryaspirationSignificantpostoperativediscomfortSectionII-monitoringandcareinPACU18Consequences:Incidence:Withoutprophylacticintervention,roughlyonethirdofpatientswhoundergoinhalationalanesthesiawilldevelopPONV(range:10%to80%).

High-riskfactorsFemalegenderHistoryofmotionsicknessorPONVNonsmokingUseofpostoperativeopioidsSectionII-monitoringandcareinPACU2.2.7Postoperativenauseaandvomiting19

Prophylacticmeasures

Modificationoftheanesthetics(propofol)Pharmacologicintervention(ondansetron,droperidol,Dexamethasone)

Treatment:antiemetics

SectionII-monitoringandcareinPACU2.2.7Postoperativenauseaandvomiting20Commonlyusedantiemetics

Anticholinergics(Scopolamine,0.3-0.65mg,iv)

Antihistamines(Hydroxyzine,12.5-25mg,im)

Phenothiazines(Promethazine,12.5-25mg,im)

SerotoninReceptorAntagonists(Ondansetron,4mg,iv)Vasopressors(Ephedrine,25mg,im)

Corticosteroids(Dexamethasone,4-8mg,iv)SectionII-monitoringandcareinPACU2.2.7Postoperativenauseaandvomiting212.2.8DeliriumSectionII:MonitorandcareinPACUDefinition:

Anacute

changeincognitionordisturbanceofconsciousnessthatcannotbeattributedtoapreexistingmedicalconditionormedicationIncidence:

About10%inpatientsmorethan50yundergoingelectivesurgery22repairofhipfracture(>35%)bilateralkneereplacement(41%)SectionII:MonitorandcareinPACUPreoperativeriskfactors:

Advancingage,Cognitiveimpairment,Decreasedfunctionalstatus,Alcoholabuse,PrevioushistoryofdeliriumIntraoperativeriskfactors:

Surgicalbloodloss,Hematocritlessthan30%,Bloodtransfusion2.2.8Delirium23SectionII:MonitorandcareinPACUManagement:Toexcludeortreatiatrogenicfactors(pain,inadequatehydration,hypoxemia,hypercapnia,electrolyteimbalance)

Toidentifythehigh-riskpatientTocontroltheirbehaviorandavoidself-inflictedinjuryPharmacologictherapy:intravenoussedatives2.2.8Delirium242.2.9HypothermiaandShiveringSectionII:MonitorandcareinPACUIncidence:65%aftergeneralanesthesia33%afterepiduralanesthesia

Mechanism:ThermoregulatorymechanismMorerapidrecoveryofspinalfunctionthanbrain25SectionII:MonitorandcareinPACUClinialeffects:IncreasingoxygenconsumptionandCO2production

IncreasingCO,HRandBP

Inhibitingplateletfunction,coagulationfactoractivity,anddrugmetabolismTreatment:

IdentificationandtreatmentofhypothemiaDrugs:Opioids,ondansetron,clonidine

2.2.9HypothermiaandShivering262.3AntagonistsadministrationAntagonistsofneuromuscularblockingdrugs

(e.g.Neostigmine)TobeadministeredwhenspontaneousrecoveryisoccurringAntagonistsofsedatives

(e.g.Flumazenil)NotbeadministereduntilbreathisadequatelyrecoveredAntagonistsofopioids(e.g.Naloxone)

TobeadministeredcarefullytitratedintravenousdosesTokeepinminditwillalsoantagonizeopoid-inducedanalgesia

SectionII:MonitorandcareinPACU27SectionIIIDischargecriteriaBreathing:AbletobreathedeeplyandcoughfreelyOxygensaturation

(PulseOximetry):>95%whilebreathingairCirculation:Stablesystemicbloodpressure(baseline)Consciousness:Fully

awake(baseline)Activity:Abletomoveextremitiesoncommand3.1Maincriteria28StewardPost-AnaestheticRecoveryScoreConsciousnessFullyawake:2Havingresponseforstimulation:1Noresponseforstimulation:0AirwayCouldcoughaccordingtoinstruction:2Airwaykeepingopenandclear:1Needingairwaysupport:0BodymovementConsciousbodymovement:2Unconsciousbodymovement:1Nobodymovement:0SectionIII:ManagementofPACU293.2Indicationsforkeepingtheendotracheal

cathetersHemodynamicinstabilityPersistenthypoxemiawithpooltreatmentAirwayobstructionishighlypossibleafterextubationUnconsciousness(Delayedawakening,cerebralinjury)Somecriticaldiseases(MODSorMOF,ARDS,DIC)Somemajorsurgery(heartorlungsurgery,livertransplantation)SectionIII:Dischargecriteria303.3Informationgiventotheward/ICUSurgicalprocedureandtypeofanesthesiaIntraoperativedrugsIntraoperativebloodlossandurineoutputIntraoperativefluidandbloodreplacementAnestheticandsurgicalcomplicationsSectionIII:Dischargecriteria31SectionIVE