Immediate post-anesthesia care

PACU Admission - The First Five

Immediate assessment upon patient arrival from the OR. A structured handoff (e.g., SBAR) is crucial, followed by the primary survey.

📌 ABCDE Approach:

• Airway: Ensure patency; note any artificial airway.
• Breathing: Check respiratory rate, effort, and SpO₂ (goal >92%). Auscultate lungs.
• Circulation: Monitor BP, HR, and ECG. Assess peripheral pulses and temperature.
• Disability: Evaluate level of consciousness (e.g., GCS) and motor/sensory function.
• Exposure: Inspect surgical site for bleeding/hematoma. Check all drains, catheters, and IV lines.

⭐ The Aldrete Score is used to assess recovery after anesthesia. A score of ≥9 is typically required for discharge from PACU.

PACU Complications - Recovery Roadblocks

• Airway & Breathing

  • Hypoxemia ($SpO_2$ < 92%): Most common cause is atelectasis (tongue obstruction, laryngospasm).
    • Management: Jaw thrust/chin lift, ↑ FiO2, positive pressure ventilation. Consider naloxone for opioid reversal.
  • Hypoventilation (↑ $pCO_2$): Residual effects of anesthetics/opioids.
    • Management: Stimulate patient, support ventilation, reverse agents.

• Cardiovascular

  • Hypotension (↓ SBP < 90 mmHg): Suspect hemorrhage first, then vasodilation.
    • Management: IV fluid bolus, vasopressors (phenylephrine).
  • Hypertension (↑ SBP > 180 mmHg): Pain, anxiety, bladder distension.
    • Management: Treat cause (analgesia), IV labetalol or hydralazine.

• Neurologic & Other

  • Emergence Delirium: Common in kids & elderly. Rule out hypoxia.
  • PONV (Post-Op Nausea/Vomiting): Treat with ondansetron.
  • Hypothermia (< 36°C): Causes shivering, ↑ O2 demand. Use forced-air warmers.

⭐ High-Yield: In an unconscious PACU patient, the most common cause of airway obstruction is the tongue falling back and occluding the pharynx.

PACU Discharge - The Green Light

Discharge from the Post-Anesthesia Care Unit (PACU) hinges on physiologic stability. The Aldrete score is the primary tool used.

• Aldrete Score Criteria: Assesses five key areas to determine recovery.

  • Activity: Able to move 4 extremities voluntarily or on command.
  • Respiration: Able to breathe deeply and cough freely.
  • Circulation: Blood pressure ± 20% of pre-anesthetic level.
  • Consciousness: Fully awake.
  • O₂ Saturation: SpO₂ >92% on room air.

• Discharge Threshold: A score of $ \ge 9 $ is typically required.

⭐ Patients must void within 6-8 hours post-op to rule out urinary retention, especially after spinal anesthesia.

High‑Yield Points - ⚡ Biggest Takeaways

• Airway patency is paramount; watch for laryngospasm and hypoventilation from residual anesthesia.
• Assess hemodynamic stability; hypotension may signal hemorrhage or anesthetic-induced vasodilation.
• Postoperative nausea and vomiting (PONV) is common; treat with antiemetics like ondansetron.
• Shivering and hypothermia are frequent; manage with forced-air warmers.
• Suspect malignant hyperthermia with unexplained tachycardia, hyperthermia, and muscle rigidity.
• The Aldrete score determines PACU discharge readiness, assessing key physiological parameters.