9 the Post Anesthesia Care Unit

8/14/2019 9 the Post Anesthesia Care Unit

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Postanesthesia CareCare Unit


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Postanesthesia Care UnitPostanesthesia Care Unit(PACU)(PACU)

to provide close monitoring and care to patientsto provide close monitoring and care to patientsrecovering from anesthesia and sedation.recovering from anesthesia and sedation.

assuring safety to the transition betweenassuring safety to the transition betweenanesthesia and the fully awake state,anesthesia and the fully awake state,before patients are transferred tobefore patients are transferred tounmonitored general wards.unmonitored general wards.

The PACU is staffed by a dedicated team of anThe PACU is staffed by a dedicated team of an

anesthesiologist, nurses and aides.anesthesiologist, nurses and aides.


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LocationLocation

located close to the operating suitelocated close to the operating suite

good access to immediate radiology,good access to immediate radiology,

blood bank, blood gas, and other clinicalblood bank, blood gas, and other clinicallaboratory services.laboratory services.

near the ICUnear the ICU


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sizesize

determined by the surgical caseload ofdetermined by the surgical caseload ofthe institution.the institution.

Approximately 1.5 PACU beds perApproximately 1.5 PACU beds per

operating room utilizedoperating room utilized

An open ward is optimal for patientAn open ward is optimal for patient

observationobservation

at least one isolation roomat least one isolation room

A separate pediatric PACUA separate pediatric PACU


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FacilitiesFacilities

The ward itself should have largeThe ward itself should have largedoors, adequate lighting, efficientdoors, adequate lighting, efficientenvironmental control and sufficientenvironmental control and sufficientelectrical and plumbing facilities.electrical and plumbing facilities.

the bed spacesthe bed spaces central nursing station and physiciancentral nursing station and physician

stationstation storage and utility roomsstorage and utility rooms


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Each bed space should have piped-inEach bed space should have piped-in

oxygen, air and vacuum for suctionoxygen, air and vacuum for suction

(both intermittent pressure for gastric(both intermittent pressure for gastricsuction and high pressure for airwaysuction and high pressure for airway

and chest suction).and chest suction).


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Drugs and equipment for routine care (ODrugs and equipment for routine care (O22,,

suction, and monitors) and advancedsuction, and monitors) and advancedsupport (mechanical ventilators,support (mechanical ventilators,pressure transducers, infusionpressure transducers, infusionpumps, and crash cart) must bepumps, and crash cart) must be

readily available.readily available.A crash cart containingA crash cart containing

cardiopulmonary resuscitationcardiopulmonary resuscitationequipment and emergency drugsequipment and emergency drugs

should be available and fully stockedshould be available and fully stockedat all times.at all times.


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The postanesthesia care unit should be well lighted, spacious, and

equipped to deal with any possible postanesthetic emergency. A

central nursing and physician station is useful. Each bedside

should be fully equipped with air, oxygen and suction.


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PersonnelPersonnel

nursing ratio 1:3 (one nurse to everynursing ratio 1:3 (one nurse to everythree patients) or 1:2 or 2:1three patients) or 1:2 or 2:1

A charge nurse should oversee nursingA charge nurse should oversee nursing

care.care. Most PACUs are under the medicalMost PACUs are under the medical

direction of the anesthesia departmentdirection of the anesthesia department The anesthesiologist is usuallyThe anesthesiologist is usually

responsible for patient discharge to theresponsible for patient discharge to thepostsurgical ward, ICU or home.postsurgical ward, ICU or home.


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Admission to the PACUAdmission to the PACU

Transport from the OR is carriedTransport from the OR is carried

out under direct supervisionout under direct supervision

of the anesthetist.of the anesthetist.with the head of the bed elevatedwith the head of the bed elevated

or in the lateral decubitusor in the lateral decubitus

position, face maskposition, face mask..


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ReportReport the anesthesiologist should give thethe anesthesiologist should give the

nurse a full report of the eventsnurse a full report of the eventsduring surgery.during surgery.

This report should include theThis report should include thepatients name, age, surgicalpatients name, age, surgicalprocedure, medical problems,procedure, medical problems,preoperative medications, allergies,preoperative medications, allergies,anesthetic drugs and methods, fluidanesthetic drugs and methods, fluid

and blood replacement, blood loss,and blood replacement, blood loss,urinary output, gastric output, andurinary output, gastric output, andsurgical or anesthetic complicationssurgical or anesthetic complicationsencountered.encountered.


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Discharge ConsiderationsDischarge Considerations

Before discharge, the patient who hasBefore discharge, the patient who hasundergone general anesthesia should beundergone general anesthesia should bearousable and oriented, have stable vitalarousable and oriented, have stable vitalsigns for at least the prior hour and besigns for at least the prior hour and be

comfortable.comfortable. Patients who have had recent large dosesPatients who have had recent large doses

of narcotic analgesics should be observedof narcotic analgesics should be observedfor at least 30 minutes.for at least 30 minutes.


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The patient should be able to obtainnursing help while in the surgical ward if

necessary.

Patients discharged withoutsupplemental oxygen need to have their

arterial oxygen saturation measured bypulse oximetry while they are breathingroom air.

Discharge of the patient from therecovery room following regionalanesthesia depends on the type of blockused and sedation administered.


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Uncomplicated regional blocks do notUncomplicated regional blocks do not

require recovery in the PACU.require recovery in the PACU.Postoperative monitoring is indicatedPostoperative monitoring is indicatedwhen heavy sedation was administered, awhen heavy sedation was administered, acomplication from the block occurredcomplication from the block occurred(e.g., intravascular injection of a local(e.g., intravascular injection of a local

anesthetic or pneumothorax), or whenanesthetic or pneumothorax), or whenrequired by the nature of the surgery.required by the nature of the surgery. A full description of the patients courseA full description of the patients course

should then be given by the recovery roomshould then be given by the recovery room

nurse to the ward nurse before the patientnurse to the ward nurse before the patientis transferred.is transferred.


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HemodynamicHemodynamic

complicationscomplications

HypotensionHypotension (4% of(4% ofadmissions)admissions) HypertensionHypertension (1% to 2%)(1% to 2%)

ArrhythmiasArrhythmias (4%)(4%) Myocardial ischemia andMyocardial ischemia and

infarctioninfarction


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HypotensionHypotensionInadequate venous returnInadequate venous return

b.b. True hypovolemia.True hypovolemia.Ongoing hemorrhage,Ongoing hemorrhage,inadequate fluid replacement, osmoticinadequate fluid replacement, osmoticpolyuria and fluid sequestrationpolyuria and fluid sequestration

c.c. Relative hypovolemiaRelative hypovolemia positive pressurepositive pressureventilation, intrinsic positive end-ventilation, intrinsic positive end-

expiratory pressure, pneumothorax,expiratory pressure, pneumothorax,pericardial tamponade.pericardial tamponade.

VasodilationVasodilation

Decreased inotropyDecreased inotropy

Myocardial ischemia and infarction,Myocardial ischemia and infarction,arrhythmias, congestive heart failure,arrhythmias, congestive heart failure,negative inotropic drugs, sepsis,negative inotropic drugs, sepsis,hypothyroidism, and malignanthypothyroidism, and malignanthyperthermiahyperthermia


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HypertensionHypertension

Etiology: preexisting hypertensiveEtiology: preexisting hypertensive

disease, pain, bladder distention,disease, pain, bladder distention,

fluid overload, hypoxemia, increasedfluid overload, hypoxemia, increased

intracranial pressure (ICP) andintracranial pressure (ICP) andadministration of vasoconstrictiveadministration of vasoconstrictive

agents.agents.

Hypertension may present withHypertension may present with

headache, visual disturbances,headache, visual disturbances,dyspnea, restlessness, and chestdyspnea, restlessness, and chest

pain, but is often asymptomatic.pain, but is often asymptomatic.


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Management aims at restoring bloodManagement aims at restoring bloodpressure close to what is normal for eachpressure close to what is normal for each

patient.patient. If needed, IV or sublingual drug.If needed, IV or sublingual drug.

3.3. Beta-adrenergic blockers:Labetalol,Beta-adrenergic blockers:Labetalol,propranolol and esmololpropranolol and esmolol

4.4. Calcium-channel blockers: Verapamil,Calcium-channel blockers: Verapamil,diltiazem, Nifedipinediltiazem, Nifedipine

5.5. HydralazineHydralazine

6.6. Nitrates: Nitroglycerin, Sodium nitroprussideNitrates: Nitroglycerin, Sodium nitroprusside

7.7. Alpha-adrenergic blockers: phentolamine,Alpha-adrenergic blockers: phentolamine,

labetalollabetalol


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Myocardial ischemia andMyocardial ischemia and

infarctioninfarctionT-wave changesT-wave changes

ST-segmentST-segment elevation or depression.elevation or depression.


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ArrhythmiasArrhythmias

Increased sympathetic outflow,Increased sympathetic outflow,hypoxemia, hypercarbia, electrolytehypoxemia, hypercarbia, electrolyteand acid-base imbalance,and acid-base imbalance,myocardial ischemia, increased ICP,myocardial ischemia, increased ICP,

drug toxicity, and malignantdrug toxicity, and malignanthyperthermia are possiblehyperthermia are possibleetiologies of perioperativeetiologies of perioperativearrhythmias.arrhythmias.

In the presence of more worrisomeIn the presence of more worrisome

rhythm disturbances, supplementalrhythm disturbances, supplementalOO22 should be delivered and propershould be delivered and proper

treatment begun while the etiologytreatment begun while the etiologyis investigated.is investigated.


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Respiratory complicationsRespiratory complications

HypoxemiaHypoxemia (0.9% of(0.9% of

admissions),admissions),

HypoventilationHypoventilation (0.2%)(0.2%)

Upper airway obstructionUpper airway obstruction

(0.2%)(0.2%)


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HypoxemiaHypoxemia

Causes of hypoxemia include theCauses of hypoxemia include thefollowing:following:

2.2. AtelectasisAtelectasis

3.3. HypoventilationHypoventilation4.4. Upper airway obstructionUpper airway obstruction

5.5. BronchospasmBronchospasm

6.6. Aspiration of gastric contentsAspiration of gastric contents

7.7. Pulmonary edemaPulmonary edema

8.8. PneumothoraxPneumothorax

9.9. Pulmonary embolismPulmonary embolism


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HypoventilationHypoventilation

Hypoventilation is an inappropriately low-Hypoventilation is an inappropriately low-minute ventilation and results inminute ventilation and results inhypercapnea and acute respiratoryhypercapnea and acute respiratoryacidosis. When severe, hypoventilationacidosis. When severe, hypoventilationproduces hypoxemia, COproduces hypoxemia, CO22 narcosis, andnarcosis, and

ultimately apnea.ultimately apnea.Etiologies of postoperative hypoventilationEtiologies of postoperative hypoventilation

may be divided in two groups:may be divided in two groups:n Decreased ventilatory driveDecreased ventilatory drive

n Pulmonary and respiratory musclePulmonary and respiratory muscleinsufficiencyinsufficiency


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Upper airway obstructionUpper airway obstruction

Principal signs are the lack of adequate airPrincipal signs are the lack of adequate airmovement, intercostal and suprasternalmovement, intercostal and suprasternalretractions, and discoordinateretractions, and discoordinateabdominal and chest wall motion duringabdominal and chest wall motion during

inspiration.inspiration.Common etiologies include:Common etiologies include:

3.3. Incomplete recoveryIncomplete recovery

4.4. LaryngospasmLaryngospasm

5.5. Airway edemaAirway edema6.6. Wound hematomaWound hematoma

7.7. Vocal cord (Vocal cord ( ) paralysis) paralysis


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Guidelines for extubationGuidelines for extubation

1.1. Adequate arterial PaOAdequate arterial PaO22..

2.2. Adequate breathing pattern.Adequate breathing pattern.

3.3. Adequate level of consciousness forAdequate level of consciousness forcooperation and airway protection.cooperation and airway protection.

4.4. Full recovery of muscle strength.Full recovery of muscle strength.


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Before proceeding with extubation, the

PACU anesthesiologist should be aware ofpreexistent airway problems in the eventthat reintubation is necessary.Supplemental O

2

is administered, the

endotracheal tube, mouth, and pharynxsuctioned, and the tube removedfollowing a positive-pressure breath.


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Renal complicationsRenal complications

OliguriaOliguria PolyuriaPolyuria Electrolyte disturbancesElectrolyte disturbances


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OliguriaOliguriaurine output less than 0.5 mL/kg per hour, buturine output less than 0.5 mL/kg per hour, but

common sense must be used.common sense must be used.

Hypovolemia is the most frequent cause ofHypovolemia is the most frequent cause ofpostoperative oliguria.postoperative oliguria.

The pre-, post-, and intra-renal causesThe pre-, post-, and intra-renal causes

4.4. Prerenal oliguria includes conditions thatPrerenal oliguria includes conditions that

decrease renal perfusion pressure. Besidesdecrease renal perfusion pressure. Besideshypovolemia, other causes of a decreasedhypovolemia, other causes of a decreasedcardiac output must be considered.cardiac output must be considered.

5.5. Intrarenal: acute tubular necrosis secondary toIntrarenal: acute tubular necrosis secondary tohypoperfusion (e.g., shock or sepsis), toxinshypoperfusion (e.g., shock or sepsis), toxins

(e.g., nephrotoxic drugs or myoglobinuria) and(e.g., nephrotoxic drugs or myoglobinuria) andtrauma.trauma.

6.6. Postrenal: urinary catheter obstruction, trauma,Postrenal: urinary catheter obstruction, trauma,and iatrogenic damage.and iatrogenic damage.


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PolyuriaPolyuriaurine output disproportionately high forurine output disproportionately high for

a given fluid intake.a given fluid intake.

2.2. Excessive volume administration.Excessive volume administration.

3.3. Pharmacologic diuresis.Pharmacologic diuresis.

4.4. Nonoliguric renal failure.Nonoliguric renal failure.5.5. Osmotic diuresis may be caused byOsmotic diuresis may be caused by

hyperglycemia, alcohol intoxication,hyperglycemia, alcohol intoxication,and administration of hypertonicand administration of hypertonicsaline, mannitol, or parenteralsaline, mannitol, or parenteralnutrition.nutrition.


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Electrolyte disturbancesElectrolyte disturbances

hyperkalemiahyperkalemia and acidemia.and acidemia.

HypokalemiaHypokalemia and alkalemiaand alkalemia

HypomagnesemiaHypomagnesemia


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Delayed awakeningDelayed awakening Neurologic damageNeurologic damage Emergence deliriumEmergence delirium Peripheral neurologic lesionsPeripheral neurologic lesions

Neurologic complicationsNeurologic complications


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Delayed awakeningDelayed awakening

2.2. The most frequent cause is theThe most frequent cause is thepersistent effect of anesthesia.persistent effect of anesthesia.

3.3. Decreased cerebral perfusionDecreased cerebral perfusion

4.4. Metabolic causes of delayedMetabolic causes of delayedawakening include hypoglycemia,awakening include hypoglycemia,sepsis, preexistingsepsis, preexistingencephalopathies, and electrolyteencephalopathies, and electrolyte

or acid-base derangements.or acid-base derangements.


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Emergence deliriumEmergence delirium

is characterized by excitement alternating withis characterized by excitement alternating withlethargylethargy , disorientation, and, disorientation, andinappropriate behavior.inappropriate behavior.

Delirium may more frequently occur in theDelirium may more frequently occur in the

elderly and in those with a history of drugelderly and in those with a history of drugdependency or psychiatric disorders.dependency or psychiatric disorders.

Many drugs used perioperatively may precipitateMany drugs used perioperatively may precipitatedelirium: ketamine, opioids,delirium: ketamine, opioids,

benzodiazepines, large doses of atropine.benzodiazepines, large doses of atropine.


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Delirium may be a symptom ofDelirium may be a symptom ofongoing pathology (e.g.,ongoing pathology (e.g.,hypoxemia, acidemia,hypoxemia, acidemia,hypoglycemia, intracranial injury,hypoglycemia, intracranial injury,sepsis, severe pain, and alcoholsepsis, severe pain, and alcoholwithdrawal).withdrawal).

Treatment is symptomatic:Treatment is symptomatic:supplemental Osupplemental O22, fluid and, fluid and

electrolyte replacement, andelectrolyte replacement, and

adequate analgesia. Anadequate analgesia. Anantipsychotic medication such asantipsychotic medication such ashaloperidol, Benzodiazepines mayhaloperidol, Benzodiazepines maybe added.be added.


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Peripheral neurologicPeripheral neurologic

lesionslesionsmay follow direct surgicalmay follow direct surgical

damage and improperdamage and improper

intraoperative positioning.intraoperative positioning.

Early neurological consultationEarly neurological consultation

for diagnosis andfor diagnosis and

rehabilitation are crucial for arehabilitation are crucial for afull recovery.full recovery.


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Principles of painPrinciples of pain

managementmanagement OpioidsOpioids NonsteroidalNonsteroidal Adjuvant analgesicsAdjuvant analgesics Regional sensory blocksRegional sensory blocks

Patient-controlledPatient-controlled



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managementmanagementAdequate analgesia begins in the OR and continuesAdequate analgesia begins in the OR and continues

in the PACU.in the PACU.

Opioids (IV or peridural) are the mainstay ofOpioids (IV or peridural) are the mainstay ofpostoperative analgesia. Intramuscularpostoperative analgesia. Intramuscularinjections, ordered on an as needed basis,injections, ordered on an as needed basis,

have essentially no indication in adult PACUhave essentially no indication in adult PACUpatients.patients.

Fentanyl, Morphine, MeperidineFentanyl, Morphine, Meperidine

Nonsteroidal anti-inflammatory drugs (NSAIDs):Nonsteroidal anti-inflammatory drugs (NSAIDs):Ketorolac,ibuprofen, acetaminophenKetorolac,ibuprofen, acetaminophen

Regional sensory blocksRegional sensory blocks

Patient-controlled and continuous epiduralPatient-controlled and continuous epiduralanalgesiaanalgesia


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Postoperative nausea andPostoperative nausea and

vomitingvomiting (PONV)(PONV)

PONV typically occurs in 20 to 30%PONV typically occurs in 20 to 30%of surgical cases.of surgical cases.

aspiration of emesis, gastricaspiration of emesis, gastricbleeding, and wound hematomasbleeding, and wound hematomasmay occur with protracted ormay occur with protracted orvigorous retching or vomiting.vigorous retching or vomiting.

Troublesome PONV can prolongTroublesome PONV can prolongrecovery room stay andrecovery room stay andhospitalization.hospitalization.


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Body temperatureBody temperature

changeschanges HypothermiaHypothermia

HyperthermiaHyperthermia


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ACUTEACUTE

POSTOPERATIVEPOSTOPERATIVE

PAIN MANAGEMENTPAIN MANAGEMENT


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Definition and HistoryDefinition and History

Acute pain: a normal, predicted, physiological response to an

adverse chemical, thermal or mechanical stimulus

-Surgery, trauma and acute illness

-Short duration, recent onset, poss. prolong or chronic

Consequences of surgical procedure

-Cardiopulmonary compression-Autonomic hyper-stimulation

-Increased blood clotting

-Water retention and delayed GI function

-Immune dysfunction

-Pain:

Surgical injuries and emotional reactions

Fear of pain (59%) and postponing surgery (8%)


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Definition and HistoryDefinition and History

Consequences of acute postop pain

-Increased M&M

Cardiovascular : HTN, ischemia, MI, arrhythmia, DVT

Pulmonary: atlectasis, pneumonia, bronchospasm

CNS: agitation, elevated ICP, strokeGI/GU: ileum, constipation, N/V, urinary

retention

Surgical site: poor healing, tissue breakdown, bleeding

-Prolonged hospital staying-High health care cost

-Chronic pain syndrome

-Negative physical and psychological effects


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Definition and History

Historically, postop pain mgt has been inadequately

-Patient education and communication

-Staff training/knowledge on acute pain management

-Pain assessment before and after analgesia-Timely evaluation and follow-up

Recently, more attention to the pain

-1992/ANA: comfort & pain relief in dying patient

-1995/APS: pain scale as the fifth vital sign

-2000/JCAHO: pain assess and mgt as a patients right

-2003/NPCPA: the decade of pain control and research


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Professional Guidelines for Pain Management

Agency/year Guideline

-ASA/95,04 Practice guidelines for acute pain managementin the perioperative setting

-APS/03 Principles of analgesic use in the treatment ofacute pain and cancer pain

-EAU/03 Guidelines on pain management

-VHADD/02 Clinical practice guideline for the managementof postoperative pain

-JCAHO/00 Pain assessment and management:

an organizational approach-AHCPR/93 Acute pain management

-IASP/92 Task force on acute pain


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Acute Pain Service Models

APS with Anesthesiologists and other care providers 24hr availability Personal training via up-to-date knowledge/skills/techniques

Multi-models with more aggressive ways Comprehensive techniques

New pharmacological agents Reliable assessment of pain

Pre/intra/postoperative evaluation Timely monitoring and management

Pain scale, response and adverse reactions to treatment

Life-threaten emergency

Outcome A score of 3 or below without adverse reactions Patients satisfied and early discharged


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Assessment of Pain & Management

Subjective report by patient-Pain score: 0-10 (no pain to worst pain in life)

-Satisfaction score

-Anxiety, fear, culture/religious influence, communication

Objective report by APS

-General condition

Vital signs, mental status

-Clinical functionsDeep breath, cough, ambulation

-Monitoring response to therapy and adverse reactions

P i P i E l i & Pl i


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Preoperative Patient Evaluation & Planning

Proactive individualized APS planningType of surgeryExpected severity of acute painPatients previous experience with pain

Type of analgesia (PO,IV,IM, PCA, epidural)

Response to the treatment

Any adverse reactions

Any surgical complicationsCo-existing conditions

Cardiac, pulmonary, renal, diabetic neuropathy,sickle cell anemia, mental status

Allergies and drugs (anticoagulation, pain pills)Risk-benefit ratio for the available techniques


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Type of Surgery & Severity of Pain

Minor Intermediate Major

Surgery Inguinal Hernia Fem/Hip ORIF Thoracotomy

Breast Biopsy Hysterectomy Nephrectomy

Varicose veins Exp. Lap ColectomyClosed reduction Lower abd. Upper abd.

Knee arthroscopy Maxillofacial TKR/THR

Gyn laparoscopy Cesarean section AAA

Pain mild-moderate moderate-severe very severe


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Preoperative Preparation of the Patient

Adjustment or continuation of medicationsWithdrawal syndrome

Surgical-related stress/physiological reactions

Optimizing patients conditions

Premedication prior to surgery Initiation of analgesic pain management program

Reduction of preexisting pain and anxiety

Patient and family educationBehavioral pain control techniques/communication

Emotional/stress relief and support

Optimal use of PCA and PCEA


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Intraoperative Evaluation & Management

Preemptive analgesia (Reducing sensitization)

-Local infiltration

-IV opioids

-Epidural bolus or continued infusion

Lower sympathetic tone

-SBp 20-30% below base-line

-HR 50-70s

Emergence or spontaneous breath

-RR is key (12-15/min)

-Adequate oxygenation and ventilation

P t ti E l ti & M t


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Postoperative Evaluation & Management

PACU

Rapid control pain score to 3-4 or below IV Toradol or PO weak opioid for mild pain IV bolus of Morphine for mod-severe pain Fontanels or combined Morphine for very severe pain Peripheral nerve blockade

Then continue multi-model pain management In-patient: PCA or PCEA

Epidural or PNB catheter

IV, IM or PO Out-patient: PO opioid, NSAIDs,

Durogenic patchFrequently Assessment of pain/satisfaction scale

Adjustment management

Treatment of adverse reactions


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Therapeutic Models for Acute Pain

Systemic opioids

-Enteral Oral (PO): via digestion, absorption, liver metabolism then to blood

Rectal, Sublingual (SL): directly into vein

-Parenteral

Transdermal/Transmucosal/Subcutaneous (SQ): slow absorption Intramuscular (IM): 15-30 min reach peak blood concentration

Intravenous (IV): bolus or infusion/PCA

Neuroaxial (intrathecal/epidural)

Afferent neural block with L.A. (+/- opioid)-Neuraxial (intrathecal or epidural)

-Peripheral plexus/nerve & incision

NSAIDs

Others

S t i O i id


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Systemic Opioids

-Type

Hydrophilic: Morphine, Hydromorphone, Meperidine Lipophilic: Sufentanil, Fentanyl

Mixed: DepoDur (liposome slow-release morphine)

-Enteral: Short-acting: Codeine, Hydrocodone, Oxycodone, Hydromorphone

Long-acting: MsContin, OxyContin, Methadone

Newer agents: Avinza, Kadian (longer-acting morphine)

-Parenteral: Short-acting: Fentanyl, Sufentanil, Remifentanil

Intermittent: Meperidine, Hydromorphone Long-acting: Morphine, Duromorphine

Transdermal: Duragesic patch (Fentanyl)

Transmucosal: ACTIQ (Fentanyl)

Th ti M d l f A t P i


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IV-PCA

-Potential efficacy for most in-house patients withmoderate to severe pain procedures

-Improving pain scores & patient satisfaction

-Equivocal to PCEA

-Better or more constant analgesia with basal infusion

Agents: bolus(mg) lockout(min) basal(mg/hr)

Morphine 0.5-3 5-10 0.5-1Hydromorphone 0.1-0.5 5-15 0.2-0.5

Meperidine 50-100 5-15 5-50Fentanyl 0.015-0.05 3-10 0.02-0.1

Methadone 0.5-3 10-20


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IV-PCA overdose Clinical symptom and sign Hypotension Asleep, drowsing, and seizure (Meperidine) Respiratory depression, apnea and death

Estimated death rate: 1in 10,000-30,000

Programming errors of PCA machine

Drug prep errors Error drug

Error concentration Basal infusion

Patient conditions and co-exited morbidities

Inadequate observation from care provider


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Inadequate IV-PCA Usually managed by non-anesthesiologists

Lack of understanding of adverse physiologic

squealer Myths about opioid risks persist

Addiction, dependence

Lack of application on multimodal therapyBolus or breakthroughRegional techniques

Analgesic gap in transition to oral route


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Epidural analgesia with L.A.

-Local anesthetics Conc.(%) OnsetDuration Lidocaine 1-2 quick short

Mepivacaine 1-2 quick intermittent

Bupivacaine 0.1-0.125 (T) slow long

> Ropivacaine-Vasoconstrictor: Epinephrine, Phenylephrine

Lowing systemic absorption

Enhancing blockade and prolonging duration

Testing dose


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Pros and Cons of Neuraxial Analgesia

Advantages Improving postop pain control Reducing pulmonary complication & GI motility Reducing incidence of postop myocardial infarction (T>L) Reducing hypercoagulability & DVT (L.A.>opioid)

Better patients satisfaction/life-quality & early discharge Contraindications

Absolute RelativeNo consent/refuse Around area infection

Sepsis or bacteremia Demyelinating CNS diseases

Elevated ICP DementiaInfection at site Hypovolemia

L.A allergy LBP/Prior spinal surgery

Coagulopathy Drugs (ASA)


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Complications of Neuraxial Analgesia

-L.A. allergy & toxicity

Hypersensitivity: skin rashes to anaphylaxis

Toxic symptoms:

CV CNS

dysrhythmia circumoral numbness

bradycardia tinnitus, blurred visionhypotension agitation, confusion

asystole seizure

-Narcotics

Pruritus, ileum, urinary retention, N/V

Respiratory depression and apnea

Complications of Neuraxial Analgesia


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Complications of Neuraxial Analgesia-Headache

Spinal H/A, Co-existed H/A, Meningitis, Pneumocepheral

-Infections Epidural abscess, Arachnoiditis

Risk factor: Steroids dependent, Sepsis, Localized lesions

-Hematoma Blood tap or vascular injury

Anticoagulopathy:

-Drugs: Coumadine, Plavix, LMWH, ASA, Herbs

-Congenital disease: vw disease, hemophyllis

Prevention:-Stopping anticoagulators and rechecking coax profiles

5d for Coumadine, 12d for Plavix, 12hr for LMWH

-Correcting coagulopathy before giving/withdrawing

FFP, DDAVP, cryoprecipitate, specific factor(VIII)


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R i l A l i T h i


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Regional Analgesia Techniques

Peripheral nerve blocks (PNB) Intercostal, Interpleural Ilioinguinal and 3-in-1 block Plexus: Interscalene, Axillary, Brachial, Femoral, Ankle block Penile and dorsal nerve block

IV block: Bier Block Field infiltration

Intraartricular block (peripheral opoid receptor) 1-5 mg morphine +/- bupivacaine(0.25%)

Systemic absorptive rate:Intercostal>caudal/spinal>epidural>brachial plexus>SQ

Adjuvant (clonidine, epinephrine, opioids) Reducing L.A. dose with less motor block Improving analgesia



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Local anesthetics

Neural blockade sequence:Sympathetic block: temp. elevation/vasodilatationLoss of pain and temp. sensationLoss of proprioception, touch and pressure sensationMotor block

Agents Lido Mepiv Bupiv RopivConc.(%) 1-2 1 .25-.5 .2

Onset (min) 5-10 >10 10-15 10-15

Duration(min) 30-120 45-90 120-240 120-360

Max dose(mg) 300/500 300/500 175/225 200/Spinal/epidural +/+ -/+ +/+ -/+

PNB/infiltra. +/+ +/+ +/+ +/+

IVor 2%,epi >1% >.5% >.5%


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-AdvantagesPatient satisfaction, fully function

Better & prolonged analgesia

Lower opioid consumption

Lower adverse reactions: opioid via L.A.

Early discharge

-Disadvantages

Experienced, high skillful providerDifficult position for certain blocks

Potential nerve injuries

Th ti M d l f A t P i


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NSAIDS

Inhibiting cyclooxygenase (COX), low prostaglandins COX-1 in various tissues with normal physiologic regulations COX-2 only induced by pain & inflammation COX-2 inhibitors (Vioxx, Celebrex):

Analgesia/anti-inflammation

No side effects of opioid, steroids and other NSAIDS (COX1&2)

Increase risk of AMI, CVA in patients with cardiovascular disease

Precautious PUD, GI or CNS hemorrhage; kidney, liver, or platelet dysfunction

Acetaminophen alone or combined with opioid Mild to moderate pain

Ketorolac (Toradol): only parenteral form Potent analgesia: 30 mg = 10mg morphine, same onset & duration Loading: 30-60 mg, then 15-30 mg q6h for up to 5 days



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Others-NMDA antagonist:

Reducing hyperalgesia, allodynia and chronic pain

Ketamine, Dextromethorphan, Methadone

Ketamine (.5-1mg/kg): preemptive analgesia & few side effects

-Alpha 2 agonist: Clonidine, Dexmetodomidine

Effective in reducing postoperative opioid requirements

-Physical therapy, behavior relaxants, TENS

-Specific: Adequate drainage of urine, bloody and fluids

Surgical re-exploration

M lti M d l T h i f P i M t


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Multi-Model Techniques for Pain Management

Most effective analgesic technique (single one)

-Afferent neural blockade with local anestheticsNeuroaxial (spinal or epidural) block

Peripheral nerve block

Local infiltration

-Intrathecal opioids

-Epidural opioids and clonidine

-PCA with opioids

-NSAIDS and other agents

Multi-drugs are more potent than single one

Multi-routes are more potent than single route


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Multimodal Techniques for Acute Pain Control

Two or more analgesic agents via a single agent-Epidural or intrathecal opioids combined with

L.A. via epidural opioid

L.A. via epidural L.A.

Clonidine via epidural opioid

-IV opioids combined with

Clonidine

KetorolacKetamine

-Oral opioid combined

NSAIDs, COXIBs, or acetaminophen


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Cost of Postoperative Pain Management

Cost of medications

Health care providers

-Physician

-Nurse

Cost of instruments & equipments

-PCA pump and tubes

-Epidural and spinal trays

-Peripheral nerve block kits

Length of hospitalization

Pain related complications

Outcomes

Ch ll f C h i APS


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Challenge of Comprehensive APS

-Increasing demands of anesthesiologistsAnesthesiologist shortage

Increased surgical loading

Patient population change

-Hospital staff shortage

-Financial LimitationLower or no reimbursement for IV-PCA

Lower reimbursement for continuous PNBsO.K. for Epidurals

-Malpractice risksEpidural, intrathecal > PNB > IV, IM, PO


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Thanks for your attention!Thanks for your attention!

Documents

9 the Post Anesthesia Care Unit