Overview of post-anesthetic care for adult patients
- David B Glick, MD, MBA
David B Glick, MD, MBA
- Medical Director, Post-Anesthesia Care Unit
- Department of Anesthesia & Critical Care
- The University of Chicago
Timely recognition and management of issues that arise in the immediate postoperative period may be life-saving. The likelihood that a specific complication will arise for a given patient is determined by the nature of the procedure, the anesthetic techniques used, the patient's comorbidities, and preoperative medical assessment and optimization.
This topic serves as an overview for post-anesthetic care and the most common problems encountered in the post-anesthesia care unit (PACU). Preoperative evaluation and preventive strategies are discussed elsewhere. (See "Preoperative medical evaluation of the adult healthy patient" and "Management of cardiac risk for noncardiac surgery" and "Evaluation of preoperative pulmonary risk".)
PHASES IN THE POST-ANESTHESIA CARE UNIT
It is common practice for most patients who receive general anesthesia, regional anesthesia, or monitored anesthesia care to be monitored in a post-anesthesia care unit (PACU) prior to discharge from the hospital or transfer to a ward bed. The exception is critically ill patients and those who are intubated, who may bypass the PACU and be recovered directly in an intensive care unit (ICU). In most PACUs, medical oversight of patients is the responsibility of the anesthesiology service.
Initial handoff — The initial handoff from the anesthesia care team and other intraoperative personnel (eg, circulating nurse and surgeon) to personnel in the PACU is typically standardized (table 1). This handoff includes review of pertinent medical history, allergies, the surgical procedure performed; total dose and last timing for opioids, muscle relaxants, and antibiotics; total fluids administered including colloids and blood products; critical intraoperative laboratory values if these were obtained (eg, hemoglobin or hematocrit, glucose and potassium levels, last activated whole blood clotting time [ACT] if heparin was administered), airway management and any difficulties; untoward intraoperative events; prophylactic medications previously administered for postoperative nausea and vomiting (PONV); the plan for postoperative analgesia; and discussion of disposition after PACU discharge (eg, to home, a hospital ward, or an ICU bed). (See "Patient handoffs", section on 'The handoff process' and "Patient handoffs", section on 'Strategies for effective handoffs'.)
Phase I and II care — PACU care is typically divided into two phases. Phase I emphasizes ensuring the patient's full recovery from anesthesia and return of vital signs to near baseline. Phase II recovery focuses on preparing patients for hospital discharge, including education regarding the surgeon's postoperative instructions and any prescribed discharge medications.
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- PHASES IN THE POST-ANESTHESIA CARE UNIT
- Initial handoff
- Phase I and II care
- ASSESSMENT, MONITORING, AND CARE
- Initial assessment and care
- Assessment after neuraxial block
- INCIDENCE OF COMPLICATIONS
- POSTOPERATIVE NAUSEA AND VOMITING
- RESPIRATORY COMPLICATIONS
- CARDIOVASCULAR COMPLICATIONS
- NEUROPSYCHIATRIC COMPLICATIONS
- Intraoperative awareness with recall
- Delayed emergence and emergence delirium
- Visual disturbance
- Spinal epidural hematoma
- HYPOTHERMIA OR HYPERTHERMIA
- INABILITY TO VOID
- Risk factors
- Evaluation and treatment
- DISCHARGE FROM THE POST-ANESTHESIA CARE UNIT
- Standard discharge criteria
- Fast-track discharge criteria
- POST-ANESTHETIC EVALUATION
- RESOURCES AND GUIDELINES
- American Society of Anesthesiologists (ASA)
- SUMMARY AND RECOMMENDATIONS