PACU (Post Anesthesia Care Unit)

PendahuluanSalah satu perubahan paling penting dalam praktek bedah : rawat inap rawat jalan.USA : bedah rawat jalan 70% dari seluruh operasi terencana (elektif).Inggris: 34% pada tahun 1989 menjadi 49% pada tahun 2001 , 2002.Keuntungan bedah rawat jalan: biaya lebih murah, menguntungkan untuk pasien dan keluarganya. McGrath B, Chung F. Anesth Clin of North America, June 2003; 21(2)

Definisi PemulihanPemulihan segera : saat pasien bangun dari anestesi.Pemulihan Intermediet: bila pasien mencapai kriteria untuk dipulangkanPemulihan Jangka Panjang: bila pasien kembali ke keadaan fisiologis seperti sebelum di operasi.McGrath B, Chung F. Anesth Clin of North America, June 2003; 21(2)

Phase II (Intermediate) recoverystep down unit, PADSSPhase I (Early) recovery, PACU, Modified Aldrete ScorePhase III (late) recovery, home

Postanesthesia Recovery Score (Modified Aldrete Score)Color criteria, change to Oxygen Saturation

Oxygen Saturation : 2= SpO2 > 92% on room air 1= Supplemental O2 req to maintain SpO2>90% 0= SpO2

Fast tracking SAFEAdvent of rapid and short acting drugs for induction and maintenance of anesthesia (Propofol, Sevoflurane, Desflurane, remifentanyl).Patient can achieve Aldrete score 9 or 10 upon arriving in the PACU.Fast tracking refers to ability to transfer directly from OR to Phase II recovery area.

DischargeA successful ambulatory surgical program depends on the appropriate and time discharge of patient after anesthesia.Using PADSS : base on vital sign (BP,HR,RR, temp), ambulation, nausea/vomiting, pain, surgical bleeding.Recovery Phase I : Modified Aldrete Score. Phase II Recovery: PADSS

Can patients be safely discharged without tolerating oral fluid?Higher incidence of nausea and discharge delay among mandatory drinker.Oral fluid withheld for 4-6 hours postop, incidence vomiting less than the group that drank.PGPAC: drinking of fluid should not be part of a discharge protocol

Is voiding necessary before discharge?Traditionally voiding as a prerequisite to discharge.Postoperative urinary retention caused by surgical manipulation, bladder distention, pain, anxiety, residual effect of spinal/epidural.PGPAC: should not be part of a discharge protocol.Seek medical help if unable to void within 6-8 hours of discharge.

AFTER GUIDELINES

Discharge of patients after Spinal anesthesiaSame discharge criteria as GA.SA widely used in the ambulatory setting.Lower incidence of PONV, drowsiness, post operative pain than GA.TNS with lidocaineDischarge : RA more faster than GA, GA more faster than RA, no difference discharge time.

Factors delaying dischargeIncreasing age: a 10 year difference in age being associated with a 2% change in length of stay.Preoperative predictors of delayed of discharge: ENT, strabismus surgery, CHF.Intraoperative factors: GA, long duration of surgery, present intraoperative cardiac eventPostoperative: pain, PONV, logistic factor.

Common PACU problems and treatment : Pain PONV

Postoperative pain and PONV are 2 factors that commonly prolong postoperative stay after ambulatory surgery.

Postoperative painMain criteria performing ambulatory surgery is minimal postoperative pain, and can be controlled with oral analgesia.Pain is still a common reason for delay in discharge, for contact with the family doctor, for unanticipated hospital admissions.Important to understand the pattern of pain and define predictive factor for severe pain (orthopedic, duration of surgery : >90 minutes 10% severe pain, > 120 minutes 20% severe pain)

Postoperative analgesics in the ASU Twersky RS. ASA Annual Meeting, 2002

DrugDoseRouteFentanylMeperidineMorphineAcetaminophenCodeineKetorolac1,0-2,0 ug/kg0,5-1 mg/kg0,05-1,0 mg/kg60 mg/year or 25-40 mg/kg0,5-1 mg/kg30-60 mg (0,5-1 mg/kg)IvImIv/imPo/prPoIm/iv

PONVRemain problem after ambulatory surgery.Avoid using N2O, Prostigmine.20-30% after GA, 35% of patients after discharge home.Antiemetic with droperidol 0,625-1,25 mg iv, droperidol 0,625 + metoclopramide 10 mg iv, ondansetron 4-8 mg iv, dexamethasone 8 mg iv.

Twersky RS. ASA Annual Meeting, 2002

Common causes of Nausea and vomiting in outpatients (1)Predisposing factors: female, motion sickness, morbid obesity, early pregnancy. Increasing gastric volume: excessive anxiety.Premedicants: narcotic analgesics

Common causes of Nausea and vomiting in outpatients (2)Anesthetic agents : inhaled gas, intravenous drugs.Surgical procedures: laparoscopy, strabismus correction, insertion of PE tube, orchidopexy.Postoperative factors: hypotension, pain.

Incidence of PONV cause by anesthetics agent (%)

SEVOISOHALDESPROP6-74 (2-20)33-69(8-33)6-20(8-13)20-3812-20(0-7)

Other factors delaying dischargeSore throat, headache, dizziness, drowsiness.Thirst, nausea, dizziness, drowsiness avoid by perioperative hydration with 20 ml/kg.Overall post discharge symptoms: 45% for pain, 17% for nausea, 8% for vomiting.

Patient educationPatient have a responsible individual to accompany at home after discharge (reduce adverse outcomes, increase patient comfort and satisfaction).Provided written instruction (diet, medications, activities, phone number).Not consume alcohol, drive vehicles, make important decisions for 24 hours.

Patients education (2)Should not drive for 24 hour after an anesthetic less than 1 hour, if the duration is 2 hour or more, should abstain from driving for 24 hour (Anesthesia with thiopentone, halothane).New drugs (Sevoflurane, Desflurane, propofol, remifentanyl) : 3 hours

Treatment recommendationProphylaxis and treatment of pain & PONV.Supplemental oxygen.Fluid administration and management.Normalizing patient temperature.Pharmacological agent for the reduction of shivering.Antagonism of the effect of sedatives, analgesics, and neuromuscular block.

Factors that determine satisfactionFriendliness of the OR staff.Surgeons discussion of the operative finding.Management of postoperative pain.Starting their I.v smoothly.Avoidance of delay.

Tarazi EM, Philips BK. Anesth 1995;83

SummaryFormulating an ambulatory anesthesia plan that balances drugs effectiveness, side effect profile, patients preference, and associated reduction of total cost.Patient arrive for ambulatory surgery anesthesia with the mistaken perception that the experience will be no more difficult than walk in the park

THANK YOU VERY MUCH

ReferencesPractice Guidelines for Postanesthetic Care. Anesthesiology, March 2002;96(3).Twersky R. Recovery and Discharge of the Ambulatory Anesthesia Patient. ASA Annual Meeting, Oct 2002.McGrath B, Chung F. Postoperative recovery and discharge. Anesth Clin of North America, June 2003; 21(2)

*PACU merupakan periode pascabedah yang memerlukan pengorganisasian khusus. PACU yang baik akan memperbaiki outcome pembedahan.