Postoperative

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By Craig L. Muetterties, M.D., and Donald E. Martin, M.D.

This section summaries post anesthesia care standards that are adopted by American Society of Anesthesiologists Standards.

Standard I
Standard II
Standard III
Standard IV
Standard V

Standard I

All patients who have received general anesthesia, regional anesthesia or monitored anesthesia care shall receive appropriate post anesthesia management.1

  • A Post Anesthesia Care Unit (PACU), or areas that provide equivalent post anesthesia care, shall be available to receive patients after anesthesia care. An example of a PACU is a Surgical Intensive Care Unit. All patients who receive anesthesia care shall be admitted to the PACU or its equivalent, exceptby specific order of the anesthesiologist responsible for the patient’s care.
  • The medical aspects of care in the PACU (or equivalent area) are governed by policies and procedures that have been reviewed and approved by the Department of Anesthesiology.
  • The design, equipment and staffing of the PACU shall meet requirements of the facility’s accrediting and licensing bodies.

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Standard II

A patient transported to the PACU will be accompanied by a member of the anesthesia care team who is knowledgeable about the patient’s condition. The patient should be continually evaluated and treated during transport with monitoring and support that’s appropriate to the patient’s condition.

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Standard III

Once the PACU arrives, the patient will be re-evaluated and a verbal report should be provided to the responsible PACU nurse by a member of the Anesthesia Care team who accompanies the patient.

  1. The patient’s status on arrival in the PACU should be documented.
  2. Information concerning the preoperative condition and the surgical/anesthetic course should be transmitted to the PACU nurse.
  3. The member of the Anesthesia Care Team should remain in the PACU until the PACU nurse accepts responsibility for the nursing care of the patient.

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Hypothermia (Core Temperature Less Than 36 Degrees Celsius or 96.8 Degrees Fahrenheit)

Hypothermia is common during the perioperative period in the absence of active warming of patients. Hypothermia has been associated with a number of adverse consequences, including:

  • increased susceptibility to infection;
  • impaired coagulation and increased transfusion requirements;
  • cardiovascular stress;
  • cardiac complications, postanesthetic shivering, and thermal discomfort.

The perioperative maintenance of normothermia and the use of forced-air warming reduce shivering and improve patient comfort and satisfaction.

The literature supports the use of forced-air warming devices for normalizing patient temperature and reducing shivering. Normothermia should be a goal during emergence and recovery.

When available, forced-air warming systems should be used for treating hypothermia. Forced-air convection warming systems are available and effective for restoring body temperature to greater than or equal to 36 degrees Celsius (or 96.8 degrees Fahrenheit) postoperatively.

Assess:

  • Measure patient temperature on admission.
  • Is the patient aware of a sensation of being cold?
  • Is there shivering, piloerection or cold extremities?

Treat:

  • Cover exposed areas on the patient (passive insulation).
  • Institute forced-air warming.
  • Consider other modalities such as warming IV fluids, increasing room temperature, warming and humidifying oxygen.
  • Continue to monitor patient temperature at least every 30 minutes until normothermia is achieved.

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Pain

  • Document patient pain on admission to PACU using analog scale.
  • Document interventions that have been employed to relieve pain and continue to reassess pain score.

Peripheral Neuropathies

The Practice Advisory for the Prevention of Perioperative Peripheral Neuropathies was last published in 2000, and the revised practice advisory provides specific positioning recommendations for the upper and lower extremities, as well as specific recommendations for protective padding. Read more

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Standard IV

The patient’s condition should be evaluated continually in the PACU

  1. The patient should be observed and monitored by methods appropriate to the patient’s medical condition. Particular attention should be given to monitoring oxygenation, ventilation, circulation, level of consciousness, and temperature. During recovery from all anesthetics, a quantitative method of assessing oxygenation such as pulse oximetry should be employed in the initial phase of recovery.*  This is not intended for application during the recovery of the obstetrical patient to whom regional anesthesia was used for labor and vaginal delivery.
  2. An accurately written report of the PACU period should be maintained. Use of an appropriate PACU scoring system is encouraged for each patient on admission, at appropriate intervals before discharge and at the time of discharge.
  3. General medical supervision and coordination of patient care in the PACU should be the responsibility of an anesthesiologist.
  4. There should be a policy to ensure the availability of a physician capable of managing complications and providing cardiopulmonary resuscitation for patients in the PACU.

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Standard V

A physician is responsible for the discharge of the patient from the Post Anesthesia Care Unit.

  1. When discharge criteria are used, they must be approved by the Department of Anesthesiology and the medical staff. They may vary depending on whether the patient is discharged to a hospital room, the Intensive Care Unit, a short stay unit, or home.
  2. In the absence of the physician responsible for the discharge, the PACU nurse should determine that the patient meets the discharge criteria. The name of the physician accepting responsibility for discharge should be noted on the record.

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References

  1. Postoperative Anesthesia Care Standards 
  2. http://www.aspan.org

Anesthesiologists

Physicians Protecting Patients