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.
- Apfelbaum JL, Silverstein JH, Chung FF, et al. Practice guidelines for postanesthetic care: an updated report by the American Society of Anesthesiologists Task Force on Postanesthetic Care. Anesthesiology 2013; 118:291.
- Hines R, Barash PG, Watrous G, O'Connor T. Complications occurring in the postanesthesia care unit: a survey. Anesth Analg 1992; 74:503.
- Kluger MT, Bullock MF. Recovery room incidents: a review of 419 reports from the Anaesthetic Incident Monitoring Study (AIMS). Anaesthesia 2002; 57:1060.
- Rosero EB, Joshi GP. Nationwide incidence of serious complications of epidural analgesia in the United States. Acta Anaesthesiol Scand 2016; 60:810.
- Bateman BT, Mhyre JM, Ehrenfeld J, et al. The risk and outcomes of epidural hematomas after perioperative and obstetric epidural catheterization: a report from the Multicenter Perioperative Outcomes Group Research Consortium. Anesth Analg 2013; 116:1380.
- Moen V, Dahlgren N, Irestedt L. Severe neurological complications after central neuraxial blockades in Sweden 1990-1999. Anesthesiology 2004; 101:950.
- Lee LA, Posner KL, Domino KB, et al. Injuries associated with regional anesthesia in the 1980s and 1990s: a closed claims analysis. Anesthesiology 2004; 101:143.
- SCIP-Inf-7 www.qualitynet.org (Accessed on March 02, 2010).
- Madrid E, Urrútia G, Roqué i Figuls M, et al. Active body surface warming systems for preventing complications caused by inadvertent perioperative hypothermia in adults. Cochrane Database Syst Rev 2016; 4:CD009016.
- Sessler DI. Perioperative thermoregulation and heat balance. Lancet 2016; 387:2655.
- Good KK, Verble JA, Secrest J, Norwood BR. Postoperative hypothermia--the chilling consequences. AORN J 2006; 83:1054.
- Frank SM, Fleisher LA, Olson KF, et al. Multivariate determinants of early postoperative oxygen consumption in elderly patients. Effects of shivering, body temperature, and gender. Anesthesiology 1995; 83:241.
- Sun KO. Severe postoperative shivering and hypoglycaemia. Anaesth Intensive Care 1993; 21:873.
- De Witte J, Sessler DI. Perioperative shivering: physiology and pharmacology. Anesthesiology 2002; 96:467.
- Frank SM, Fleisher LA, Breslow MJ, et al. Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events. A randomized clinical trial. JAMA 1997; 277:1127.
- Lenhardt R, Marker E, Goll V, et al. Mild intraoperative hypothermia prolongs postanesthetic recovery. Anesthesiology 1997; 87:1318.
- Jeyadoss J, Thiruvenkatarajan V, Watts RW, et al. Intraoperative hypothermia is associated with an increased intensive care unit length-of-stay in patients undergoing elective open abdominal aortic aneurysm surgery: a retrospective cohort study. Anaesth Intensive Care 2013; 41:759.
- Billeter AT, Hohmann SF, Druen D, et al. Unintentional perioperative hypothermia is associated with severe complications and high mortality in elective operations. Surgery 2014; 156:1245.
- Wolberg AS, Meng ZH, Monroe DM 3rd, Hoffman M. A systematic evaluation of the effect of temperature on coagulation enzyme activity and platelet function. J Trauma 2004; 56:1221.
- Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med 1996; 334:1209.
- Stewart PA, Liang SS, Li QS, et al. The Impact of Residual Neuromuscular Blockade, Oversedation, and Hypothermia on Adverse Respiratory Events in a Postanesthetic Care Unit: A Prospective Study of Prevalence, Predictors, and Outcomes. Anesth Analg 2016; 123:859.
- Karalapillai D, Story D, Hart GK, et al. Postoperative hypothermia and patient outcomes after major elective non-cardiac surgery. Anaesthesia 2013; 68:605.
- Choi KE, Park B, Moheet AM, et al. Systematic Quality Assessment of Published Antishivering Protocols. Anesth Analg 2017; 124:1539.
- Baldini G, Bagry H, Aprikian A, Carli F. Postoperative urinary retention: anesthetic and perioperative considerations. Anesthesiology 2009; 110:1139.
- Stallard S, Prescott S. Postoperative urinary retention in general surgical patients. Br J Surg 1988; 75:1141.
- Pavlin DJ, Pavlin EG, Gunn HC, et al. Voiding in patients managed with or without ultrasound monitoring of bladder volume after outpatient surgery. Anesth Analg 1999; 89:90.
- Ding YY, Sahadevan S, Pang WS, Choo PW. Clinical utility of a portable ultrasound scanner in the measurement of residual urine volume. Singapore Med J 1996; 37:365.
- Patel MI, Watts W, Grant A. The optimal form of urinary drainage after acute retention of urine. BJU Int 2001; 88:26.
- Ead H. From Aldrete to PADSS: Reviewing discharge criteria after ambulatory surgery. J Perianesth Nurs 2006; 21:259.
- Aldrete JA. The post-anesthesia recovery score revisited. J Clin Anesth 1995; 7:89.
- Aldrete JA, Kroulik D. A postanesthetic recovery score. Anesth Analg 1970; 49:924.
- Chung F. Recovery pattern and home-readiness after ambulatory surgery. Anesth Analg 1995; 80:896.
- White PF, Song D. New criteria for fast-tracking after outpatient anesthesia: a comparison with the modified Aldrete's scoring system. Anesth Analg 1999; 88:1069.
- Overdyk FJ, Harvey SC, Fishman RL, Shippey F. Successful strategies for improving operating room efficiency at academic institutions. Anesth Analg 1998; 86:896.
- Duncan PG, Shandro J, Bachand R, Ainsworth L. A pilot study of recovery room bypass ("fast-track protocol") in a community hospital. Can J Anaesth 2001; 48:630.
- Centers for Medicare & Medicaid Services (CMS). State Operations Manual Revised Appendix A, Regulations and Interpretive Guidelines for Hospitals.Rev. 2015; TAG A-1005.
- Standards for postanesthesia care. http://www.asahq.org/quality-and-practice-management/standards-and-guidelines (Accessed on September 14, 2016).
- Post-Anesthesia Evaluation Policy (August 2014). https://www.asahq.org/~/media/sites/asahq/files/public/resources/practice%20management/post%20anesthesia%20evaluation%20policy%202014%2008%2011.pdf.
- Membership of the Working Party:, Whitaker Chair DK, Booth H, et al. Immediate post-anaesthesia recovery 2013: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia 2013; 68:288.
- 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