Clinical Problems
in the Postanesthesia Recovery Room
(PACU)
Heidi Eriksson, MD, PhD
Helsinki University Central Hospital
Finland
Recovery room incidents: a review of 419 reports from the
Anaesthetic Incident Monitoring Study (AIMS) Kluger
and Bullock Anaesthesia 2002
• The Australian incident monitoring study (Anesthesia and Intensive
Care 1993)
– incident reporting study
– voluntary, self-reporting audit of actua/potential incidents that
occur during anesthesia
• 8372 reports , 478´(18%) in PACU
Recovery room incidents:
a review of 419 reports from the Anaesthetic Incident
Monitoring Study (AIMS)
• 92 % in adults
• 90 % during daytime hours
• 4 % at night
Kluger and Bullock. Anaesthesia 2002
Factors influencing stay in the postanesthesia care unit
Seago J et al. J Clin Anaesth 1998
• Patient history and age were not predictive!
• Postoperative pulmonary/airway problems
– desaturation, stridor, obstruction
• Postoperative cardiovascular problems
– hypo/hypertension, chest pain/ECG changes, pulmonary
oedema/HF
• Length of surgery
• Unexplained - due to organizational factors ??
American Society of AnesthesiologistsPhysical Status Classification
(ASA-PS)
• is not an indicator of perioperative risk
– Perioperative risk
» preoperative medical status
» nature on the anesthetic technique
» nature of the surgical procedure
low risk- intermediate risk- high risk
• does not take into account
• age
• complexity of the operation
• is a measure of preoperative medical status
Preoperative assessment
Type of procedure & recovery room incidents reported to
AIMS
General surgery
Orthopedics
Ear, nose and throat
Opthalmology
Gynecology
Urology
Vascular
Dental and maxillofacial
Plastic
Cardiothoracic
Obstetric
Electroconvulsive
Neurosurgery
Pain block
Radiology
Vascular access
118
72
42
33
30
28
25
14
12
12
10
6
5
2
1
28 %
17 %
10 %
8%
7%
7%
6%
3%
3%
3%
2%
1%
1%
0.5 %
0.2 %
1
0.2 %
Kluger and Bullock. Anaesthesia 2002
Primary presenting problem & recovery room incidents
reported to AIMS
Cardiovascular
Respiratory
Airway
Drug error
CNS
Equipment
Communication problems
Hypotermia
Regional block problems
Inadequate documentation
Hyperthermia
Trauma
Dental problems
Renal
Skin
Blood transfusion
Facility limitations
Gastrointestinal problems
99
97
86
44
32
27
7
6
4
4
3
3
2
1
1
1
1
1
24 %
25 %
21 %
11 %
8%
6%
2%
1%
1%
1%
1%
1%
0.5 %
0.2 %
0.2 %
0.2 %
0.2 %
0.2 %
Kluger and Bullock. Anaesthesia 2002
Presenting problem in 99 cardiovascular incidents out of
419 PACU incidents reported to AIMS
Pulmonary oedema
Hypotension
Cardiac arrest
Bradycardia
Myocardial ischemia
Tachycardia
Bleeding
Hypertension
Allergy
Radial artery ischemia
29
26
20
7
7
4
2
2
1
1
7%
6%
5%
2%
2%
1%
0.5 %
0.5 %
0.2 %
0.2 %
Kluger and Bullock. Anaesthesia 2002
Hypotension in PACU
Quick assessment
• decreased ventricular preload
– hypovolaemia
– postoperative bleeding
• reduced myocardial contractility
– myocardial ischemia
– congestive heart failure
• reduction of systemic vascular resistance
– septicaemia
– regional anesthesia/analgesia
– anaphylaxis
Hypertension in PACU
Quick assessment
•
•
•
•
pain
hypoxia
hypercapnia
anxiety/agitation
• fluid overload
– developing pulmonary oedema
• urinary retention
• untreated hypertension
Heart rhytm abnormalities in PACU
Quick assessment
•
•
•
•
pain
hypoxia
hypercapnia
hypovolaemia/hypervolaemia
• electrolyte inbalance
• metabolic acidosis
• pre-existing heart disease
• myocardial ischemia
Presenting problem in 97 respiratory incidents out of
419 PACU incidents reported to AIMS
Respiratory failure: inadequate oxygenation/ventilation
Aspiraton
Respiratory arrest
Bronchospasm
Pneumothorax
74
7
6
5
5
18 %
2%
1%
1%
1%
Kluger and Bullock. Anaesthesia 2002
Presenting problem in 97 airway incidents out of 419
PACU incidents reported to AIMS
Airway obstruction
Laryngospasm
Jaw dislocation
Foreign body (throat pack)
Failed extubation
Endobronchial intubation
59
18
2
2
1
1
14 %
4%
0.5 %
0.5 %
0.2 %
0.2 %
Kluger and Bullock. Anaesthesia 2002
Desaturation in PACU
Quick assessment
•
•
•
•
•
•
airway obstruction
laryngeal spasm
bronchospasm
hypoventilation
obesity
perfusion-ventilation
– atelectasis
– pulmonary oedema
– pneumothorax
– pulmonary embolism
– aspiration
• pain
Hypoventilation in PACU
Quick assessment
• oversedation
– residual anesthetic
• opioids
– parenteral
– epidural/intrathecal
Wheezing in PACU
Quick assessment
• laryngeal spasm (stridor)
– after thyroid operation
• bleeding
• paresis of n recurrens
• bronchospasm
– asthma
– bronchial hyper-responsivess (smoking, postviral)
– pulmonary oedema
– aspiration
– anaphylaxis
But does residual neuromuscular block put our patients
in danger?
• Muscle function and coordination of protective reflexes of the pharynx
and upper esofagus recover late
– Eriksson L et al. Anesthesiology 1997
• Ventilatory response to hypoxia is reduced (direct inhibition of
chemoreceptor activity in the carotic bodies)
– Eriksson L et al. Anesthesiology 1993, Wyon N et al Anesthesiology 1999
• Volunteers
– Difficulty in maintaining airway
– Desaturation and need for supplemental oxygen
– Disability to swallow
Eikerman et al. Anestehsiology 2003
Kopman A et al. Anesthesiology 1997
– Distress
Bissinger et al. Physiol Res 2000
• PACU time prolonged
– Murphy et al. Anesth Analg 2004
Residual neuromuscular block is a risk factor for postoperative
pulmonary complications: A prospective, randomised, and blinded study
of postoperative pulmonary complications after atracurium, vecuronium
and pancuronium
Berg et al. Acta Anaesthesiol Scand 1997
•
•
•
•
•
•
•
Manual TOF during operation
TOF 1-2/4
Reversal when 2-4/4
Extubation when 4/4
Mechanomyographically
postoperatively
Follow-up up to 6 PODs
Postoperative pulmonary
complication : pneumonic
infiltration/atelectasis in X-ray
TOF recordings at first postoperative mechanomyographic recording
Berg et al. Acta Anaesthesiol Scand 1997
Postoperative pulmonary complications
Berg et al. Acta Anaesthesiol Scand 1997
Type of surgery and the risk of pulmonary complications
Berg et al. Acta Anaesthesiol Scand 1997
Probability of postoperative pulmonary complications
Berg et al. Acta Anaesthesiol Scand 1997
Multiple logistic regression analysis relating the probability of POPC to various covariates
Residual paralysis in the PACU after single intubating dose of
nondepolarizing muscle relaxant with an intermediate duration of
action
Debaene et al Anesthesiology 2003
•
•
•
•
•
526 patients
2ED95 dose of vecuronium,
rocuronium, or atracurium
No muscle relaxant thereafter
Excluded, if reversal used
Time delay between the injection
of muscle relaxant and quantitative
measurement of neuromuscular
blockade assessed
• Conclusion: A long duration between the administration of a single
dose of an internediate-acting nondepolarizing muscle relaxant and
the arrival to PACU does not guarantee the lack of residual paralysis
• Note!
– hypothermia,
– halogenated anesthesia agents
Bedaene et al. Anesthesiology 2003
Residual neuromuscular block
Widely used tests to assess recovery from neuromuscular block
• Train-of-four ratio > 0.7 / 0.9 by peripheral nerve stimulation
• Reliable clinical tests of postoperative neuromuscular recovery
•
•
•
•
•
Sustained head lift fot 5s
Sustained leg lift fot 5 s
Sustained hand grip for 5 s
Sustained tongue depressor test
Maximun ispiratory presuure >-50 cm H20
However,
poor sensitivity
do not secure against residual block !
Pedersen et al. Anesthesiology 1990
Shorten et al. Can J Anaesth 1995
Fruergaard et al. Acta Anaesthesiol Scand 1998
Bedaene et al. Anesthesiology 2003
Residual neuromuscular block
• Significant residual block can be excluded only by objective, methods
• mechanomyography
• electromyography
• acceleromyography
• ”It is time to move from discussion to action and introduce objective
neuromuscular monitoring to all ORs. I believe that objective
neuromuscular monitoring is an evidence-based practice and should
consequently be used whenever a nondepolarizing neuromuscular
blocking agent is administered”
Eriksson L. Evidence-based practise and neuromuscular
monitoring. It,s time for routine quantitative assessment.
Anesthesiology 2003
”The ideal world is one thing, and the real world another!”
Viby-Mogensen. Postoperative residual curarization
and evidence-based anaesthesia. BJA 2000
How to avoid residual neuromuscular block? (I)
• Long acting neuronuscular blocking agents should not be used
• Antagonize the block at the end of the procedure
• Reversal initiated only when (2-)3-4/4 TOF stimulations present or
when spontaneous muscle activity is present
• Prefer tactile evaluation of response to double-burst stimulation (DBS)
to TOF stimulation
• Consider clinical signs and symptoms in relation to the response to
nerve stimulation
• Keep in mind the additive/prolonged effects caused by anesthetics and
hypothermia
Viby-Mogensen. Postoperative residual curarization
and evidence-based anaesthesia. BJA 2000
How to avoid residual neuromuscular block? (II)
• Every operating room and PACU should have an apparatus for
assessing neoromuscular blockade ( and know how to use it !)
• TOF, preferably quantitative, monitoring of the neuromuscular block
is mandatory if antagonists are not used!!
• TOF >0.9 the new ”gold standard” for full recovery
Viby-Mogensen. Postoperative residual curarization
and evidence-based anaesthesia. BJA 2000
Postoperative pain
• a complication itself ?
• aggressive pain prophylaxis in all patients
Note!
• pain must be in proportion to the operative procedure performed
– operative/postoperative complication in development
– tolerance to opioids
Postoperative pain
•
•
•
•
discomfort
agitation
PONV
sympathetic activation
– cardiovascular complications
• hypertension
– surgical bleeding
• immobilisation
– deep vein thrombosis
– pulmonary dysfunction
• chronic postsurgical pain
Opioid related side effects
•
•
•
•
PONV
drowsiness
respiratory depression
dysphoria/agitation
• gastrointestinal and bladder dysfunction
Balanced or multimodal analgesia
• Non-steroidal anti-inflammatory analgesics (NSAIDs)
• Paracetamol
• Local anesthetics
– wound infiltration /neural blockade
– liposome local anesthetics in the future?
• Combined with
– PCA
– Epidural
Cyclooxygenase-2 inhibitors in postoperative pain management.
Currest evidence and future directions
Gilron et al. Anesthesiology 2003
Efficacy of postoperative epidural analgesia.
A meta analysis
Block et al JAMA 2003
• 1404 articles in PubMed reviewed of which 1304 rejected
– Inclusion criteria
• randomization
• epidural analgesia versus parenteral opioids in adults
• VAS/Numeric rating
Efficacy of postoperative epidural analgesia ; pain at rest
Block et al. JAMA 2003
Efficacy of postoperative epidural analgesia;
incident pain
Block et al. JAMA 2003
Efficacy of postoperative epidural analgesia;
VAS recordings
Conclusion: Epidural analgesia (other than TEA with opioids only) provides better
postoperative analgesia to parenteral opioid
Block et al. JAMA 2003
Efficacy of postoperative epidural analgesia;
complications
Block et al. JAMA 2003
The ”Little big problem of anesthesia”
Postoperative nausea and vomiting (PONV)
• Patient-specific risk factors
– Female sex IA
– Nonsmoking status IVA
– History of PONV/Motion sickness IVA
• Anesthetic risk factors
– Use of volatile anesthetics IA
– Nitrous oxide IIA
– Use of intraoperative IIA and postoperative opioids IVA
• Surgical risk factors
– Duration of surgery IVA
– Type of surgery (laparoscopy, ear-nose-throat, neurosurgery, breast,
strabismus, laparotomy, plastic IVB
Consensus guidelines for managing postoperative nausea and vomiting
Gan et al. Anesth Analg 2003
Postoperative nausea and vomiting (PONV)
Keep the baseline risk low !
•
•
•
•
•
•
•
•
Regional anesthesia IIIA
Propofol for induction and maintenence IA
Intraoperative supplemental oxygen IIIB
Adequate hydration IIIA
Avoid nitrous oxide IIA
Avoid volatile anesthetics IA
Minimize intraoperative IIA and postoperative IVA opioids
Minimization of neostigmine IIA
Gan et al. Anesth Analg 2003
Algorithm for prevention of PONV
Gan et al. Anesth Analg 2003
Multimodal or balanced
antiemetic strategy
Prophylaxis of PONV
Antiemetic doses and timing in adults
Gan et al. Anesth Analg 2003
Treatment of PONV in PACU
Gan et al. Anesth Analg 2003
Perioperative mild hypothermia (34-35C);
Complications
Sessler.Perioperative hypothermia.
NEJM 1997
Perioperative maintenance of normothermia reduces the incidence
of morbid cardiac events: A randomized clinical trial. Frank et al.
JAMA 1997
Perioperative hypothermia and PACU
• cardiovascular complications
– symphathetic overactivity
– norepinephrine
• coagulapathy
– platelet function
– clotting factor enzyme function
– fibrinolytic activity
• shivering
– increased total-body oxygen consumption
– patient discomfort
• residual neuromuscular blockade
– respiratory complications
– aspiration
• prolongation of PACU stay
Perioperative hypothermia
First stage
• internal transfer of core heat to periphery i.e., internal redistribution
Second stage
• drop in core temperature as the result of heat losses
– cutaneous,
– exposure of viscera
– cold solutions
Third stage
• cutaneous vasocontriction
• core temperature remains almost stable but the heat content of the
limbs continues to fall
• Mild hypothermia 34-35 C
Sessler Anesthesiology 2001
Perioperative mild hypothermia
Delay in recovery
Lenhard et al.Mild intraoperative hypothermia
prolongs postoperative recivery Anesthesiology 2001
Postanesthesia shivering
• Involuntary movement that may affect one/several muscle groups and
generally occurs in the early recovery phase after general anesthesia
• Thermoregulatory shivering
– associated with cutaneous vasoconstriction
– physiological response to hypothermia
• Non-thermoregulatory shivering
• Overall incidence 6-66%
Risk factors for postanesthesia shivering
•
•
•
•
•
Young adult
Long surgery & anesthesia
Drop in body temperature
No active perioperative rewarming
Anesthetic used
– Halogenated agents +
– Thiopental +
– Propofol • Little opioids perioperatively
• Postoperative pain
Hypothermia and shivering in PACU
• Use forced-air blankets and warmed iv solutions
• Consider rewarming the patient before extubation
– Temperature monitoring
• Beware of altered pharmacokinetics
– monitor (and antagonize) residual neuromuscular blockade
– extubate when awake ! Increased risk of aspiration
• Treat postoperative pain promptly!
Alfonsi. Postanesthetic shivering.
Systematic review. Drugs 2001
Postanesthesia shivering: Medical treatment
Meperidine 0.4-0.85 mg/kg i.v.
Tramadol 1-2 mg/kg i.v.
Mg-sulphate 30 mg/kg i.v.
(Clonidine 0.3mg/kg i.v)
Alfonsi. Postanesthetic shivering.
Systematic review. Drugs 2001
Postoperative agitation
• Hypoxia
• Hypercapnia
• Pain
• Distension of the stomach
• Urinary retention
• Apprehension about the findings at operation or fear of pain
• (Intraoperative awareness)
• (Neurological sequalae)
Drug error related incidents out of 419 PACU incidents
reported to AIMS
Inapproriate drug
Overdosage
Inadequate drug/dosage
Misconnection/wrong route
Side-effect
Withdrawal
Allergy
17
14
6
3
2
1
1
4%
3%
1%
1%
0.5 %
0.2 %
0.2 %
Kluger and Bullock. Anaesthesia 2002
Discharge criteria from the PACU
The Association of Finnish Anaesthesiologists 1999
• conscious
• can secure his/her airway
– protective reflexes recovered
• ventilation and oxygen saturation adequate
• stable hemodynamics (heart rate, blood pressure)
• normothermia
• pain and PONV in adequate control
• motor block wearimg off (spinal, epidural)
• no surgical reasons requiring longer follow-up
• a plan for analgesics, antiemetics and intravenous fluids provided
Aldrete Score
Preoperative clinic
Operation Room
OR
High Dependency Unit
HD
PACU
Intensive Care Unit
ICU
Surgical ward
PACU
Safety
Safety
Comfort
Comfort
PACU
