Goals and Objectives – PACU 2009
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Goals and Objectives
TU Post-Anesthesia Care Unit Rotation
Rotation Director:
Michael Yarborough, MD
Learners:
CA-1 Residents
Duration:
Two Weeks
Introduction:
The immediate post-operative period is a time of significant physiologic flux as the
patient recovers from the acute derangements of the surgical insult and anesthesia. As
such, The Post Anesthesia Care Unit (PACU) was developed to monitor and care for
patients recovering from surgery and anesthesia. The PACU rotation was developed to
teach residents how to manage the problems that are commonly encountered and unique
to the PACU.
Goals:
The goals for the PACU rotation are:
1. To understand the process of recovery from anesthesia.
2. To become proficient in the management of common post-operative anesthesia
problems.
3. To become proficient in the management of PACU emergencies.
4. To understand and appreciate the role of the recovery nurse.
5. To understand the criteria for patient’s discharge from the PACU.
Objectives and Competencies:
Patient Care:
Residents must be able to provide patient care that is appropriate by gathering and
interpreting data available, make decisions, perform procedures required, manage patients
and work with the PACU and surgical staff. During the PACU rotation the resident must
demonstrate proficiency in the following patient care activities:
1. Assessment and management of post-operative pain including the use of regional
anesthesia techniques, if appropriate.
2. Proper management treatment of postoperative nausea and vomiting.
3. Management and treatment of fluid and electrolyte disorders and/or blood product
administration in the PACU.
4. Assessment and management of postoperative respiratory issues such as
postoperative croup, laryngospasm and asthma.
5. Recognition and treatment of postoperative weakness, and management of other
problems in the PACU such as postoperative delirium or anuria.
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6. Recognition and treatment of hemodynamic problems in the PACU such as
hypertension and hypotension.
7. Recognizing and assisting with the management of emergencies in the PACU
including airway obstruction and cardiac arrests.
8. Perform procedures required in the PACU such as emergency tracheal intubation,
peripheral and central venous catheterization, and arterial line placement.
9. Obtaining and interpreting appropriate laboratory and radiological studies
including:
a. Routine Laboratory Values
b. Electrocardiograms
c. Arterial Blood Gases
d. Chest X-rays
i. Central Line Placement
ii. Identification of Pneumothorax
iii. Endotracheal Tube Placement
Medical Knowledge:
During this rotation the resident will be expected to study the chapter on Postanesthesia
Care and the section on Postoperative Pain in the Pain Management chapter in Clinical
Anesthesiology by Morgan and Mikhail. Additional reading should be performed
pertaining to interesting cases or problems that may arise during the rotation and/or
assigned by faculty members. A general guideline of knowledge to be reviewed and
gained during this rotation includes:
1. Basic Science Knowledge
a. Physiological changes associated with surgery
i. CNS
ii. Respiratory
iii. Cardiovascular
iv. Renal
v. Gastrointestinal
vi. Thermoregulation
vii. Acid-Base
b. Metabolism and elimination of anesthetic drugs
i. Opioid and opioid antagonists
ii. Benzodiazepines and benzodiazepine antagonists
iii. NSAIDS
iv. Muscle relaxants and reversal agents
v. Local anesthetics
vi. Inhalational anesthetic agents
vii. Anti-emetic drugs
viii. Vasoactive agents—inotropes and vasodilators
2. Clinical Knowledge
a. Evaluation and management of common PACU problems
i.
Fluid replacement
1. Crystalloid
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ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.
xi.
xii.
xiii.
2. Colloid
3. Blood transfusions and reactions
Increased intracranial hypertension
Delayed awakening
Postoperative agitation and delirium
Postoperative pain—including epidural and regional techniques
Prolonged neuromuscular weakness
Respiratory Problems
1. Airway obstruction
2. Stridor/wheezing
3. Hypoventilation
4. Hypoxemia
5. Pulmonary aspiration
6. Pulmonary edema
a. Post-obstructive
b. Fluid Overload
Cardiovascular Problems
1. Hypertension
2. Hypotension
3. Dysrhythmias
4. Myocardial Ischemia
5. Bleeding/coagulopathies
Postoperative nausea and emesis
Renal Problems
1. Oliguria
2. Polyuria
3. Hematuria
4. Urinary retention
5. Electrolyte and metabolic abnormalities
Hypothermia/hyperthermia—including malignant hyperthermia
Anaphylaxis
Ventilator management
1. Determine when postoperative ventilation is necessary
2. Weaning of postoperative patients from ventilatory support
Practice-Based Learning and Improvement:
During the rotation the residents will be encouraged to locate, appraise and assimilate
“best practices” related to patient care in the PACU. Individual interesting cases and /or
complications are discussed with the responsible faculty at the time of their occurrence
with the intent of practice improvement. The residents are expected to utilize the
computers available to access new information applicable to individual patient care. In
addition, the medical literature pertaining to cases presented should be critically reviewed
to determine if changes in medical practice are necessary.
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Interpersonal and Communication Skills:
The PACU rotation offers the residents an excellent opportunity to learn and polish their
communication skills. There is significant interaction between surgeons, consultants,
nursing staff and others. Since parents are often present with children recovering from
anesthesia, this rotation will provide the residents an opportunity to learn the skills
required to provide information to families during the recovery of patients from
anesthesia. Residents are expected to make every effort to improve their ability to
communicate and interact properly with nurses, patients, and physicians during this
rotation.
Professionalism:
During this rotation the PACU residents are expected to demonstrate respect towards
patients, faculty and staff. They are expected to assume and demonstrate the
responsibility as being “the caring-doctor in the PACU”. This will include commitment
to ethical principles and appropriate behavior. In addition, residents will:
1. Have a commitment to ethical principles including the confidentiality of patient
information and informed consent.
2. Show sensitivity and responsiveness to patients’ culture, age, gender, and
disabilities.
Systems-Based Practice:
During this rotation the residents will learn and see in action how patient care practices
and related actions impacts health care. Residents must demonstrate an awareness of and
responsiveness to the larger context and system of healthcare and the ability to effectively
call on system resources to provide care that is of optimal value. Discussion of how a
treatment decision may impact the health system occurs on a case-by-case basis should
be had with individual faculty. By the end of the rotation, the resident should be able to
discuss several of these issues including:
1. The common reasons for unexpected hospitalization of ambulatory surgical
patients.
2. Fast-track anesthesia and patient discharge times.
M. Yarborough, M.D. - 2009