Post-operative Care

This is the care given to a patient after surgery. It includes care given during the immediate postoperative period, both in the operating room and the recovery room or post-anesthesia care unit (PACU), as well as the days following surgery. The immediate postoperative period is crucial and a time of potential danger to patients. Numerous physiological and pharmacodynamic changes occur due to surgical trauma and anesthesia.

The period can be divided into two:

1. Post Anesthesia Care (PAC) - usually in the recovery room or PACU
   • Recovery from anesthesia
   • Can range from completely uncomplicated to life-threatening
   • Must be carried out in a well-planned, protocol-based fashion
2. Post-Recovery Room Care - on the ward

PAC is the specialized care given to patients who have undergone anesthetic management. It is provided by a team of well-trained professionals in a specially designed, equipped, and designated area of the hospital known as the PACU (Post Anesthesia Care Unit).

Criteria for Shifting from OR to PACU:

• Conscious, awake, responds to simple commands
• Hemodynamic stability
• Clinical evaluation for neuromuscular blockade recovery
• Maintenance of adequate oxygen saturation
• Normothermia

PACU Admission Report:

• Identity of the patient
• Preoperative history
• Intra-operative factors:
  • Type of procedure done
  • Type of anesthesia
  • Other medical problems, allergies
  • Estimated blood loss (EBL)
• Assessment and report of the patient's status
• Post-operative instructions:
  • Pain management
  • Management of nausea and vomiting (N/V)
  • Instructions on controlling co-morbidities

Purposes of PAC:

• To enable a successful and faster recovery of patients
• To reduce post-operative morbidity and mortality
• To reduce the length of hospital stay
• To provide quality care service
• To reduce hospital and patient cost

An area where patients recover from the immediate effects of anesthesia and surgery. It is specially designated, designed, located, staffed, and equipped. The concept was introduced in 1923 and provides a setting for the detection and treatment of early post-operative complications. The level of staffing and monitoring available in the PACU can vary considerably.

Stages of PACU

The PACU is traditionally divided into phases 1 and 2.

Phase 1: has monitoring and staffing ratios equivalent to the ICU.

• It emphasizes ensuring the patient's full recovery from anesthesia and return of vital signs to near baseline.

Phase 2: a transitional period between intensive observation and either the surgical ward or home.

• For day cases, it focuses on preparing patients for hospital discharge, including education regarding the surgeon's postoperative instructions and any prescribed discharged medications.

Equipment:

1. Tray with labeled emergency drugs and IV fluids
2. Airway maintenance kits:
   • Laryngoscope with all sizes of blades
   • All sizes of Endotracheal Tubes
   • Facemasks, airways, Ambu bag
   • Tracheostomy set
3. Venturi masks, breathing systems
4. Transport ventilator
5. Suction apparatus
6. Defibrillator
7. Connectors
8. Monitors:
   • Pulse oximeter
   • Sphygmomanometer or Invasive pressure monitor
   • ECG
   • EtCO2, Temperature
9. Crash cart
10. Defibrillator
11. Breathing equipment/air supplies
12. Emergency drugs
13. IV supplies and tubing

Facilities in PACU

Facilities:

1. Fowler's cot with side rails
2. Piped Oxygen, Vacuum, and Air
3. Multiple electrical outlets
4. Large doors
5. Good lighting
6. Isolation for immune-compromised patients

Personnel:

1:1 ratio is preferred, but a 1:3 ratio is acceptable.

Monitoring

Clinical monitoring in the recovery room can be divided into assessment of:

• Airway
  • Protect airway by proper positioning of the patient's head.
  • Protect airway by clearing the airway.
  • Provide oxygen therapy.
  • Pharyngeal obstruction can occur when the patient lies on their back as there are chances for the tongue to fall back.
• Breathing
• Circulation:
  • ECG (Electrocardiogram)
  • BP (Blood Pressure) recording
  • Pulse rate
• Conscious level
• Pain score
• Operation site review
• Temperature
• Urine output where necessary
• Drugs or fluids administration

On Admission in PACU

• Monitoring equipment attached:
  • Cardiac monitor
  • Blood pressure cuff
  • Pulse oximetry
• Oxygen may be applied
• Surgical site examined
• Intravenous fluids checked
• Report obtained from the anesthesia provider
• Vital signs taken every 5 – 15 minutes
• Pain management initiated

Recovery Position

This position allows the tongue and soft palate to fall forwards away from the oropharyngeal opening. It will also prevent any blood or secretions pooling in the oropharynx and causing aspiration or laryngospasm. In patients at risk of further oropharyngeal soiling, drainage of secretions can be increased by placing a pillow beneath the patient's chest ('tonsillar position'). If the patient has to remain supine for any reason, then the use of jaw thrust, or an oropharyngeal (Guedel) airway can be invaluable in airway maintenance.

Nursing Management in Post-op Unit

The goals of nursing management in the post-op unit are:

1. To provide care until the patient has recovered from the effects of anesthesia.
2. To assess the patient, monitor vitals, including pulse volume and regularity, depth and nature of respiration, and assessment of the patient's oxygen saturation and skin color.

Supplemental Oxygen Therapy

Whenever possible, all patients recovering from anesthesia should be given supplemental oxygen (4 l/min by face mask or nasal cannula).

Pain Care

Adequate management of pain is critical in the postoperative period.

• Once the patient is vocalizing and is reasonably awake, pain levels should be assessed.
• Pain medication should be given on a regular basis and whenever necessary.

Common problems in the PACU usually result from unidentified changes in a patient's airway, breathing, or circulation, and these can almost always be rectified if identified at an early stage. They include:

• Upper airway obstruction
• Hypoxia
• Hypotension
• Hypovolemia

Other problems may include:

• Hypothermia
• Pain
• Shivering
• Nausea and vomiting
• Delayed awakening

The anesthetist should always be on hand until a patient is awake and maintain their own airway in case of severe laryngospasm necessitating re-intubation.

Common Causes of Hypoxia in Recovery Room

Common causes of hypoxia in the recovery room include:

• Airway obstruction due to an obtunded conscious level.
• Hypoventilation secondary to opioids and anesthetic agents.
• Diffusion hypoxia caused by nitrous oxide.
• Ventilation/perfusion mismatching due to:
  • Atelectasis
  • Decrease in functional residual capacity with anesthesia and supine posture.
  • Poor mucus clearance (absent/impaired cough reflex and poor ciliary function).
  • Possibly hypovolemia or pulmonary edema.

Assessment of Respiration in PACU

Assessment of respiration in the PACU includes:

• Bradypnea: This is usually due to intra-operative opioid use and, if so, will be associated with pinpoint pupils.
  • Rx: Indicated if respiratory rate is less than 8 bpm or hypoxia.
  • First, try to rouse the patient, and if this fails, consider naloxone or doxapram.
• Tachypnea: Can be associated with acidosis, hypovolemia, pain, hypoxia, or other respiratory problems.
  • Rx: Treat the cause.
    • Morphine for pain.
    • Fluid challenge for hypovolemia.
    • Oxygen therapy for hypoxia.
    • Monitor oxygenation by examining the patient's color or use of a pulse oximeter.

Assessment of Circulation in PACU

Circulation in the PACU can be assessed by:

• Palpating the pulse (thread pulse or tachycardia suggesting volume depletion).
• Feeling the peripheries (cold poorly perfused hands also suggest hypovolemia or hypothermia following long operations).

Assessment of the Surgical Site

Hemorrhage: It is a serious complication of surgery that can result in death. It can occur in the immediate post-operative period or up to several days after surgery. If left untreated, cardiac output decreases, and blood pressure and Hb level will fall rapidly.

Maintaining IV Stability

Hypovolemic shock can be avoided by timely administration of IV fluids, blood, and blood products, and medication. This includes the replacement of fluids (colloids and crystalloids) and monitoring intake and output balance.

Bradycardia is usually associated with:

• Deep anesthesia
• Vagally stimulating surgery

Rx: If the heart rate is less than 40-50 bpm or if associated with hypotension, give atropine (200-400 mcg).

Tachycardia is likely to be due to:

• Poor pain control
• Hypovolemia
• May rarely be due to atrial fibrillation or a supraventricular tachycardia

Rx: Primary treatment should be directed at the cause (morphine or a 250 ml fluid challenge).

Chart the heart rate and blood pressure so that trends over time can be more easily seen.

Assessment of Conscious Level in PACU

Assessment of the conscious level in the PACU includes:

• Observing the return of reflexes such as the eyelash reflex, swallowing, and the start of vocalization and response to commands.
• A conscious individual, as defined in the Oxford English Dictionary, is 'awake and aware of their surroundings and identity.'
• However, consciousness represents a continuum with varying depths of consciousness.

Glasgow Coma Scale (GCS) is used to provide a rapid, reproducible quantification of the depth of unconsciousness.

Where the patient has undergone regional anesthesia (spinal or epidural), the height of the block must be assessed until it is seen to be regressing.

Causes of Delayed Awakening from Anaesthesia

Causes of delayed awakening from anesthesia can be categorized as follows:

Pharmacological:

• IV anaesthetics
• Inhalational anaesthetics
• Neuromuscular block
• Benzodiazepines
• Opioids

Metabolic Causes:

• Hypoglycemia (<2.2 mmol/litre)
• Hyperglycemia
• Hypo/hypernatremia
• Uraemia
• Acidosis
• Hypothyroidism
• Hypothermia
• Hepatic/renal failure

Respiratory Failure

Neurological Causes

Uncommon Causes:

• Central anticholinergic syndrome
• Disassociative coma
• Coagulation defects

Patient Factors:

• Extremes of age
• Genetic variation
• Body habitus
• Co-morbidities
• Obstructive sleep apnea
• Cognitive dysfunction
• Seizures
• Stroke

Postoperative Shivering

Postoperative shivering is a frequent occurrence in the post-operative period and can cause:

• Discomfort and exacerbation of post-operative pain.
• Increased oxygen consumption, catecholamine release, cardiac output, heart rate, blood pressure, and intra-ocular pressure.

Techniques used to reduce shivering include:

• Increasing the ambient temperature in the theater.
• Using conventional or forced warm air blankets.
• Using warm lights.
• Using warmed intravenous fluids.
• Administration of an opioid analgesic.

Controlling Nausea and Vomiting

Nausea and vomiting are common problems in the post-operative period. Medication can be administered as per the doctor's orders. Examples include injection metoclopramide and injection ondansetron.

Patient should continue to be observed in PACU until fit for discharge to the ward area. Discharge criteria vary but should include:

• The return of preoperative conscious level and protective reflexes.
• Orientation to person, place, time, or events.
• Maintenance of a clear airway, satisfactory breathing, and oxygenation – oxygen saturation greater than 93% on room air.
• Stable pulse and blood pressure.
• Acceptable temperature.
• Urine output at least 30ml/hour for adults, 0.5ml/kg in children.
• Adequate analgesia.
• Prescribe follow-up postoperative analgesia.

Post Analgesia Discharge Scoring System

This is a modification of the Aldrete score, which also includes an assessment of pain, N/V, and surgical bleeding, in addition to vital signs and activity. A score of 9 or 10 shows readiness for discharge.

*Activity	Can move voluntarily on command
	*4 extremities	2
	2 extremities	1
	0 extremities	0
Consciousness	Fully awake	2
	Rousable to speech	1
	Not responding	0
Circulation	Blood pressure within 20% of pre-anaesthetic level	2
	Blood pressure within 20-50% of pre-anaesthetic level	1
	Blood pressure within 50% of pre-anaesthetic level	0
Respiration	Able to breath and cough freely	2
	**Dyspnoea, shallow, or limited breathing	1
	Apnoea	0
Oxygen Saturation	>92% on room air	2
	Needs O2 supplement to maintain >90%	1
	O2 saturation <90% even with O2 supplement	0

*Except if surgical site restricts, may be 2 extremities.

** Any nasal, oral, endo tube, trach tube.

Best score is usually 10/10…

Patients scoring ≥ (and/or are returned to similar pre-op status) are considered fit for discharge from the post-anaesthetic care unit (PACU).

Guidelines for Safe Discharge after Ambulatory Surgery

Vital signs must have been stable for at least 1 h

The patient must be

• Oriented to person, place, and time
• Able to void
• Able to drink clear, noncaffeinated fluids
• Able to dress
• Able to walk without assistance

The patient must not have

• More than minimal nausea and vomiting
• Excessive pain
• Bleeding

The patient must be discharged by both the person who administered anaesthesia and the person who performed surgery, or by their designates. Written instructions for the postoperative period at home, including a contact place and person, must be reinforced.

The patient must have a responsible, “vested” adult escort them home and stay with them.

Post Anesthetic Discharge Scoring System (PADSS)

Vital Signs
2 = within 20% of preoperative value
1 = 20%-40% of preoperative value
0 = <40% of preoperative value

Activity and mental status
2 = Oriented x3 AND has a steady gait
1 = Neither
0 = Moderate, requiring treatment

Pain, nausea and/or vomiting
2 = Minimal
1 = Severe, requiring treatment
0 = Moderate

Surgical bleeding
2 = Minimal
1 = Moderate
0 = Severe

Intake and output
2 = has had PO fluids OR voided
1 = Neither
0 = Neither

Total pads score is 10; Score ≥9 considered fit for discharge
PO = oral administration

Category	Score 2	Score 1	Score 0
Vital Signs	within 20% of preoperative value	20%-40% of preoperative value	<40% of preoperative value
Activity and Mental Status	Oriented x3 AND has a steady gait	Neither	Moderate, requiring treatment
Pain, Nausea, and/or Vomiting	Minimal	Severe, requiring treatment	Moderate
Surgical Bleeding	Minimal	Moderate	Severe
Intake and Output	has had PO fluids OR voided	Neither	Neither

Total pads score is 10; Score ≥9 considered fit for discharge

PO = oral administration