EMERGENCE AND POSTOPERATIVE

ANESTHETIC MANAGEMENT

Prepared by: Serkalem Teshome

Advised by instructor Wosneyeleh
OUTLINES
 Objectives
 Introduction
 Emergence and postoperative issues in anesthesia
 Guideline for extubation
 Signs and stages of anesthesia during emergence
 Preparation for emergence
 Delayed emergence
 Safety in PACU
 Admission to PACU
 Postoperative pain management
 WHO analgesic ladder
 Discharge criteria
 Postoperative period complicatiion
 Incentive spirometer
 Metabolic complication post op acid base disorder
 Giucose disorder and control
 Summary
Objectives
 At the end of this session you will be able to:
 Revise Emergence and Postoperative Issues in Anesthesia
 Rationalize the guide lines for extubation
 Identify and manage complications possible during extubation and
emergence
 Evaluate the signs and stages of anesthesia during emergence
 Manage common postoperative complications
 Revise Monitoring and Treatment of Hypoxemia & metabolic
disturbances
 List the basic extubation criteria
 Define Incentive spirometry
Introduction
 The starting point of this emergence post
operative anesthesia is to know the basic
point about post operative anesthesia and
emergence and the required techniques for
doing .
 in this days there is a growing body of
knowledge directed understanding of
PACU and emergence among hospitals
workers while they undertake surgery
Emergence and Postoperative Issues in Anesthesia

Def : Emergence is the transition process where a

patient goes from general anesthesia to awake and
spontaneously breathing.
Challenges to anesthetist
. Return of consciousness
. Neuro muscular conduction
. Air way protective reflexes
Guide lines for extubation
 Complications during extubation are common however
most airway management guideline do not dedicate as
much attention to it as intubation.

• In order to improve this it needs to have adequately

prepared extubation strategy for each patient.

 ASA guide lines: pre formulated strategy for extubation

depends on :
. Type of surgery performed
.The patients condition
.The skill of anesthetist
ASA strategy includes 4 points
 A consideration of the relative merits of awake
extubation versus extubation before the return of
consciousness.
 An evaluation for general clinical factors that may
produce an adverse impact on ventilation after the
patient has been extubated.
 The formulation of an airway management plan that can
be implemented if the patient is not able to maintain
adequate ventilation after extubation.
 A consideration of the short-term use of a device that
can serve as a guide for expedited reintubation.
Evaluation of the signs and stages of anesthesia during emergence

 Itis important to evaluate a patient’s response to

anesthetic drugs so that the patient’s care may be
appropriately managed during emergence from
anesthesia.
 Guedel defined four stages of anesthesia that occur in un
premedicated patients allowed to breathe spontaneously
during ether anesthesia.

 The Guedel system described the respiratory changes,

pupillary alterations, eye movements, and changes in
vomiting and swallowing responses that occur at various
depths of anesthesia.
Cont….
Guedel steps are
stage.1 . Amnesia and analgesia .
stage.2. Delirium From the loss of consciousness to
the onset of automatic breathing.
Stage 3. Surgical anesthesia
Stage 4 : Medullary paralysis
 From the arrest of respiration until death Anesthetic
overdose causes medullary paralysis with respiratory
arrest and vasomotor collapse. Pupils are widely
dilated and muscles are relaxed.
Cont……
 Extubation should be performed only once Stage I is
reached, that is, eyes have returned to a central position,
breathing is regular, and consciousness returns.

 The main rationale is to keep the patient’s airway secure

and protected during Stage II, with its risk of
laryngospasm and vomiting.
Preparation for emergence

 During preparation for emergence the following points

must be considered

Estimate remaining duration of surgical

procedure; decrease concentration of inhaled
anesthetic and/or rate of intravenous agent.

Do not re-administer muscle relaxants; give

reversal medications.
Cont……
 Titrateopioids to analgesia (estimate requirements
based on procedure, patient’s weight, physiological
status and opioid tolerance).

 Administer 100% oxygen for 5 to 10 minutes, e

specially if N2O used, to prevent hypoxemia.

 Return patient to supine or back-up position prior to

extubating. It is possible to extubate in the lateral or even
prone position, but provisions should be made to be able
to reposition the patient supine emergently if needed.
Extubation criteria

Two basic points(criteria ) considered are;

 Ensure that all the equipment to reintubate is available

prior to extubating.

 Assess the potential for airway obstruction

 When performing a deep extubation technique, the goal is
to extubate the patient during Stage III (surgical anesthesia),
not during Stage II.
Cont…..
Deep extubation :
 Indications :Desire to avoid coughing, “bucking,”
straining, cardiovascular response to the ETT, or
bronchospasm in a patient at low risk for
aspiration of gastric contents.
Contraindications : Full stomach, difficult
intubation ,obesity .
• Postoperative considerations

. Respiratory failure :Defined as the need to reintubate

the trachea after extubation or the need for continued
mechanical ventilation beyond 48 hours after the end of
surgery.
 The most common causes are:
. Hypoventilation due to Surgical swelling
. Aspiration of gastric contents
Cont….
 Delayed emergence can be due to:
 Residual drug effects
 Respiratory failure with significant hypercarbia
 Metabolic derangements
Neurological complications
Agitation and delirium
 Agitation upon awakening is not uncommon in children
and young patients, especially when a balanced
technique is used.
 Delirium usually resolves spontaneously within a few
minutes.
 Poor pain control may be implicated.
Cont…
 Older patients can also experience emergence delirium,
especially those who received anticholinergics that cross
the blood–brain barrier, such as scopolamine.

 Physostigmine (30 mg/kg) can be used to reverse

anticholinergics.

 Ketamine can cause hallucinations and delirium.

Hypothermia and shivering

• Postoperative hypothermia is best prevented by

intraoperative active forced-air warming.

• Hypothermia may lead to increased blood loss and

transfusion requirements (because of platelet
dysfunction) as well as poor wound healing and
increased incidence of wound infection.
Cont….
• Shivering is a physiological response to hypothermia,
using striated muscle contraction to produce heat.
However, shivering is uncomfortable for the patient and
can significantly increase oxygen consumption, leading
to myocardial ischemia in susceptible patients.

 Shivering can be treated with meperidine, 12.5 to 25

mg IV, and forced-air warming to correct hypothermia.
PONV

• Prophylaxis should be used, depending on the

patient’s risk factors.

 Emptying the stomach with a gastric tube at the end

of surgery, especially following ENT or oral
surgery, where blood can be present in the stomach,
also helps decrease the risk of PONV.

 Tx option include :dopamine antagonist

(metoclopramide , droperidol and as a last resort a
low dose (0.1 mL/kg/h) propofol infusion .
Safety in the Post anesthesia Care Unit
 The staff is obligated to optimize each patient's privacy,
dignity, and to minimize the psychological impact of
unpleasant or frightening events.

 Ensure that staff members receive appropriate

vaccinations, including that for hepatitis B.

 Practitionersmust adhere to policies for radiation safety,

infection control, disposal of sharps, universal
precautions for blood-borne diseases, and safeguarding
against exposure to pathogens .
Cont…..
 Ensure that sufficient help is available to avoid injury
while lifting and positioning patients or while dealing
with emergence situations.

 Compulsive documentation and clear delineation of

responsibility protect staff against unnecessary
medicolegal exposure.
Admission to the Postanesthesia Care Unit

 Every patient admitted to a PACU should have heart

rate, rhythm, systemic blood pressure, airway patency,
peripheral oxygen saturation, ventilatory rate/character,
and level of pain recorded and periodically monitored.

 Capinography is necessary for patients receiving

mechanical ventilation or those at risk for compromised
ventilatory function.
Cont….
 The anesthetist should never transfer responsibility to
PACU personnel until the patient's airway status,
ventilation, and hemodynamic are appropriate for the
care givers to whom he or she entrusts the patient's care.

 Leaving a patient in the hands of someone unfamiliar or

incapable of adequately handling the acuity of the
medical situation in a rush to perform the next case may
constitute abandonment of care.
Postoperative Pain Management 

 Relief of surgical pain with minimal side effects is a

major goal during PACU care and a top priority for
patients.

 Inaddition to improving comfort, analgesia reduces

sympathetic nervous system response, thereby avoiding
hypertension, tachycardia, and dysrhythmias.

 Administration of analgesics can precipitate hypotension

in an apparently stable patient, especially if direct or
histamine-induced vasodilation occurs.
Cont……..
 It is important to assess a tachycardic patient with low
or normal blood pressure who complains of pain
carefully before giving analgesics that might precipitate
or accentuate hypotension.

 Severity of pain varies among surgical procedures and

anesthetic techniques.

 Surgical pain can be effectively treated with intravenous

opioids that begins prior to the induction of surgical
anesthesia and continues throughout the post operative
course.
Cont……
 The best measure of analgesia is the patient's perception.
Heart rate, respiratory rate and depth, sweating, nausea,
and vomiting all may be signs of pain but their absence
or presence is not in itself reliable as a measure of the
presence of pain.

 Short-acting
opioids are useful to expedite discharge and
minimize nausea in ambulatory settings.
Cont……
 Disadvantages of IM administration include;
.larger dose requirements,
.delayed onset and
. unpredictable uptake in hypothermic patients.

 Oral and transdermal analgesics have a limited role in

the PACU but are helpful for ambulatory patients after
PACU discharge.
 Rectal analgesics are sometimes useful in small
children.
WHO Analgesic Ladder
 The ladder advocates a stepped approach to the use of
painkillers from these analgesic groups:
 Simple analgesics i.e. paracetamol and non-steroidal anti-
inflammatory drugs (NSAIDs)
 Weak opioids i.e. tramadol, codeine
 Strong opioids i.e. morphine, fentanyl, oxycodone,
pethidine
 Adjuvants - adjuvant analgesics are drugs which were not
originally for pain but rather for other conditions but have
been found to be effective in difficult to manage pain,
particularly neuropathic pain. They are a diverse group of
drugs that includes antidepressants, anticonvulsants
(antiseizure drugs), and others.
Cont……

 Non-opioid analgesics like Paracetamol and NSAID (if

not contraindicated) should always therefore be
prescribed with opioid analgesia (weak or strong).

 This is known as multi-modal analgesia and is the

concept that pain is best managed, not by a single drug
or therapy, but by combinations, which maximize
efficacy whilst keeping side-effects low.
 The WHO advocates that these analgesics should be given
“by the clock”, that is every 3-6 hours, rather than “on
demand.”

The advantages of the analgesic ladder include:

 Simplicity, as only a few analgesic groups are used

 Flexibility to a large variety of pain situations and also to
prescribers globally.
 Safety, in that safest drugs are used first in their lowest
effective dose.
 Emphasis on multimodal analgesia.
 DISADVANTAGES

 Itmay be too simplistic for management of certain types

of pain, especially neuropathic pain or for those who are
opioid dependant.

 Itsuggests that analgesics should be administrated

orally, which may occasionally not be appropriate, for
example, when patients are 'nil by mouth'.
Discharge Criteria

 The patient should be sufficiently oriented.

 There should be resolution of shivering.

 Airway reflexes and motor function must be adequate to maintain

patency and prevent aspiration.

 One should ensure that ventilation and oxygenation are acceptable,

with sufficient reserve to cover minor deterioration in unmonitored
settings.

 Blood pressure, heart rate, and indices of peripheral perfusion should

be relatively constant for at least 15 minutes and appropriately near
baseline.
Cont…..
 Patients should be observed for at least 15 minutes after the
last IVopioid or sedative to assess peak effects and side effects.

 Ifregional anesthetics have been administered, longer

observation could be appropriate.

 One should monitor oxygen saturation for15 minutes after

discontinuation of supplemental oxygen to detect hypoxemia.

 A planfor the continued management of likely post discharge

symptoms such as pain, nausea, headache, dizziness,
drowsiness, and fatigue must be made prior to discharge.
 Cardiovascular complications
 In the immediate postoperative period, myocardial ischemia
is rarely accompanied by chest pain, and confirming MI in a
PACU patient is dependent on the sensitivity of the cardiac
monitoring.
• causes of ST changes in those low-risk patients include
anxiety, esophageal reflux, hyperventilation, and
hypokalemia.
 In general, low-risk patients require only routine PACU
observation unless associated signs and symptoms warrant
further clinical evaluation.
 Cont….
 In contrast ST-segment and T-wave changes on the ECG in
high-risk patients can be significant even in the absence of
typical signs or symptoms.

 In this patients, any ST or T-wave changes that are

compatible with MI should prompt further evaluation to
rule out .

 Determination of serum troponin levels is indicated when

MI or infarction is suspected in the PACU.

 If the risk is high, consultation of cardiologists is mandatory

and further evaluation of the pt and investigation must have
done.
Postoperative Pulmonary Dysfunction

 Mechanical, hemodynamic, and pharmacologic factors

related to surgery and anesthesia impair ventilation,
oxygenation, and airway maintenance.

 Heavy smoking, obesity, sleep apnea, severe asthma,

and COPD increase the risk of postoperative ventilatory
events.

 Preoperative pulmonary function testing has limited

predictive value for postoperative complications,
perhaps with the exception of postoperative
bronchospasm in smokers.
Pulm. dysfunction cont’d

 Inadequate ventilation should be suspected when;

 (1) respiratory acidemia occurs coincident with

tachypnea, anxiety, dyspnea, labored ventilation, or
increased sympathetic nervous system activity;

 (2) hypercarbia reduces the arterial pH below 7.30; or

 (3)PaCO2 progressively increases with a progressive

decrease in arterial pH.
Inadequate Respiratory Drive
 During early recovery from anesthesia, residual effects
of IV and inhalation anesthetics blunt the ventilatory
responses to both hypercarbia and hypoxemia.

 Sedatives augment depression from opioids or

anesthetics and reduce the conscious desire to ventilate

 Hypoventilation and hypercarbia can evolve insidiously

during transfer and admission to the PACU.
Cont…
 Children with active or recent upper respiratory
infection are more prone to breath-holding, severe
cough, and arterial desaturations below 90% during
recovery, especially if they have a history of reactive
airway disease or secondhand smoke exposure or have
undergone intubation and/or airway surgery.
Obstructive Sleep Apnea

 (OSA) is a syndrome in which patients exhibit a period

of partial or complete obstruction of the upper airway.

 This obstruction in turn interrupts sleep patterns,

resulting in daytime hypersomnolence, decreased ability
to concentrate, increased irritability, as well as
aggressive and distractible behavior in children.

 The airway obstruction may cause episodic oxygen

desaturation, hypercarbia, and possibly lead to cardiac
dysfunction.
Cont….
 Postoperative management include analgesia, oxygenation,
patient positioning, and monitoring.

 Regional anesthesia with minimal sedation is best for

recovery versus increased use of opioids.

 Supplemental oxygen should be used immediately

postoperatively.

 pulse oximetry should be used until the patients' oxygen

saturation remains above 90% on room air while sleeping.
 
Supplemental Oxygen

 Supplemental oxygen should be administered only to

patients at high risk of hypoxemia or with low SpO2
readings .

 However, some recommend supplemental oxygen be

administered in the PACU during initial recovery and
perhaps during transport to the PACU.
Perioperative Aspiration
 During anesthesia, depression of airway reflexes places
patients at risk for intraoperative pulmonary aspiration that
may manifest in the PACU.

 Aspiration of clear oral secretions during induction, face mask

ventilation, or emergence is common and usually insignificant.

 Cough,mild tracheal irritation, or transient laryngospasm are

immediate sequelae.

 Pulmonary morbidity from perioperative aspiration varies with

the type and volume of the aspirate.
 complete upper airway or tracheal obstruction by an aspirated
object is a life-threatening emergency.

 Aspiration of acidic gastric contents during vomiting or

regurgitation causes chemical pneumonitis characterized
initially by diffuse bronchospasm, hypoxemia, and atelectasis.

 . Aspiration
of partially digested food worsens and prolongs
pneumonitis, especially if vegetable matter is present.

 The morbidity increases directly with volume and inversely

with the pH of the acidic aspirate.
Cont…
 Frequency of postoperative vomiting remains high,
especially if gas has accumulated in the stomach.

 Protective airway reflexes such as cough, swallowing,

and laryngospasm are suppressed by depressant
medications such as inhalation anesthetics, barbiturates,
and opiates, so observe carefully patients with decreased
levels of consciousness.

 Persisting effects of laryngeal nerve blocks or topical

local anesthetics used to reduce airway irritability
decrease postoperative airway protection.
Prevention
 For patients at high risk;
 preoperative administration of nonparticulate antacids such as sodium
citrate increases the pH of gastric fluid without excessively increasing
volume. Avoid particulate antacids.

 Histamine type 2 receptor blockers such as famotidine or ranitidine

reduce the volume and increase the pH of gastric secretions.

 Metoclopramide increases gastroesophageal sphincter tone and

accelerates gastric emptying.

 Inserting a nasogastric tube is often ineffective to remove particulate

matter and interferes with gastroesophageal sphincter integrity.

 High-risk patients should not have the trachea extubated until airway
reflexes are restored.
 Upper airway obstruction
 Obstruction is likely to occur at sites of anatomic narrowing
such as the hypo pharynx at the base of the tongue and the
false and true vocal cords at the laryngeal opening.

 Sites of airway obstruction are referred to as

-supraglottic (above the true cords),

- intraglottic (involving the true vocal cords) or

-infraglottic (below the true cords and above the carina

can also be divided into

.Intrathoracic and
.Extrathoracic portions.
Laryngospasm
 The reflex is mediated by the vagus nerves, with the
afferent loop conducted via the superior laryngeal nerve
to the cricothyroid muscle, causing prolonged adduction
of the vocal cords.

 Glottic stimulation is the most common precipitant, but

it can be mediated by other stimuli such as movement
and surgical stimulation.

 Intravenous (IV) lidocaine 2mg.kg given at induction,

dampens laryngeal and pharyngeal reflexes. This is only
effective if the injection is given within about 60 to 90
seconds of extubation.
Special investigations of UAO

Laryngoscopy and bronchoscopy

 Indirect laryngoscopy in a stable, cooperative patient is
useful in diagnosing foreign bodies, retropharyngeal or
laryngeal masses and other glottic pathology. In skilled
hands it is quick, simple and atraumatic.

 flexible fibreoptic bronchoscopy or laryngoscopy is

useful for both diagnosis and management of UAO.
Advantages
 Ability to directly see upper airway anatomy and function
and make an accurate diagnosis.
 Can be performed in spontaneously breathing, awake
patient.
 If care is taken it is atraumatic and should not worsen
obstruction
 Definitive airway control can usually be achieved at
conclusion of examination by railroading an endotracheal
tube into trachea .
 Direct laryngoscopy may be both diagnostic and
therapeutic. Foreign bodies, blood, vomitus, and secretions
can be suctioned or removed with forceps.
 Endotracheal intubation can be rapidly achieved under
direct vision.
Disadvantages
 Need for a skilled operator cooperative patient difficult
in presence of blood secretions.

 necessity for good local analgesia (often difficult in the

emergency setting) or general anaesthesia with the
resultant risk that spontaneous breathing and airway
control is completely lost.

 Traumatic procedure and may lead to worsened

swelling.
 Monitoring and Treatment of Hypoxemia
Oxygen Supplementation

 The argument against the use of routine oxygen

supplementation relies on the fact that continuous pulse
oximetry, now a PACU standard, readily identifies those
patients who will require oxygen therapy

 Although the practice of prophylactic oxygen therapy to all

patients after general anesthesia is controversial, most
would argue that the benefits outweigh the risks.
Cont….
 The immediate desaturation correlated positively with
patient age, body weight, ASA classification, general
anesthesia, and increased volume of intravenous fluid
greater than 1500 mL.

 The safe practice of postanesthesia care without oxygen

supplementation requires ideal conditions at all times,
that is, functioning oxygen delivery apparatus at every
bedside as well as sufficient manpower for observation
and immediate intervention.
Incentive spirometry (Sustained Maximal
Inspiration )

Defn :
 isa technique used to encourage a patient to take a
maximal inspiration using a device to measure flow or
volume.

 A maximal inspiration sustained over three seconds may

increase the transpulmonary pressure thereby improving
inspiratory volumes and inspiratory muscle performance.

 The device used to facilitate SMI, the incentive spirometer,

incorporates visual indicators of performance in order to aid
the therapist in coaching the patient to optimal performance
 Indications

 upper-abdominal or thoracic surgery, prolonged bed rest,

surgery in patients with chronic obstructive pulmonary
disease, a lack of pain control, or the presence of thoracic
or abdominal binders.

 The presence of pulmonary atelectasis

 Presence of a restrictive lung defect associated with a

dysfunctional diaphragm or involving the respiratory
musculature.
Contraindications

 The patient cannot be instructed to ensure proper use of

the device, or patient cooperation is absent or hindered

 A patient must be able to take a deep breath through the

mouth only while maintaining a tight seal on the
mouthpiece.

 The patient is unable to take a deep breath; the patient’s

vital capacity should be at least 10 mL/kg
 Precautions
 The technique is inappropriate as the sole treatment for major
lung collapse or consolidation.

 Hyperventilation may result from improper technique.

 There is potential for barotrauma in emphysematous lungs.

 Discomfort may occur secondary to uncontrolled pain.

 Development of bronchospasm may occur in susceptible patients.

 Closemonitoring of patients with hyperreactive airways should

be maintained.
Ability to Void

 The ability to void should be assessed because opioids

and autonomic side effects of regional interfere with
sphincter relaxation and promote urine retention

 Urinary retention is common after urologic, inguinal,

and genital surgery, and retention frequently delays
discharge

 When inpatients are transferred prior to voiding, ensure

urination can be monitored to avoid complications from
urinary retention.
 Oliguria
 occursfrequently during recovery and usually reflects an
appropriate renal response to hypovolemia.

 The acceptable degree and duration of oliguria vary with

baseline renal status, the surgical procedure, and the
anticipated postoperative course.

 Osmotic or loop diuretics may be useful to attenuate renal

damage.

 The use of low-dose dopamine or dobutamine has not

proven to improve renal function.
 polyuria
 Profuse urine output often reflects generous intraoperative
fluid administration, but osmotic diuresis caused by
hyperglycemia and glycosuria is another common cause,

 particularly if glucose-containing crystalloid solutions are

infusing.

 Polyuria might also reflect intraoperative diuretic

administration.

 sustained polyuria (4 to 5 mL/kg/hr) can indicate abnormal

regulation of water clearance or high-output renal failure,
especially if urinary losses compromise intravascular
volume and systemic blood pressure.
 Metabolic Complications Postoperative Acid-
Base Disorders
Respiratory acidemia
 Respiratory acidemia is frequently encountered in PACU
patients because anesthetics, opioids, and sedatives promote
hypoventilation by depressing CNS sensitivity to pH and
Paco2

 In awake, spontaneously breathing patients with adequate

analgesia, hypercarbia and acidemia are usually mild (Paco2
45 to 50 mm Hg, pH 7.36 to 7.32)
Cont….
 Symptoms of respiratory acidemia include agitation,
confusion, ventilatory dissatisfaction, and tachypnea.
Sympathetic nervous system response to low pH causes
hypertension, tachycardia, and dysrhythmias.

 Treatment consists of correcting the imbalance between

CO2 production and alveolar ventilation. Raising the
level of consciousness by the judicious reversal of
opioids or benzodiazepines improves ventilatory drive
Metabolic Acidemia

 Evaluation of acute postoperative metabolic acidemia is

relatively straight forward.

 Occasionally, ketoacidosis occurs in diabetic patients.

 During ketoacidosis, serum glucose levels are elevated

and ketones are detectable in blood or urine.

 Patients with renal failure or renal tubular acidosis

usually exhibit a preoperative metabolic acidemia
 Cont…
 A spontaneously breathing patient will increase minute
ventilation in response to metabolic acidemia and quickly
generate a respiratory alkalosis to compensate for metabolic
acidemia.

 However, general anesthetics and analgesics suppress this

ventilatory response

 Treatment consists of resolving the condition causing

accumulation of metabolic acid. For example, ketoacidosis
is treated with intravenous potassium, insulin, and glucose.
Respiratory Alkalemia

 Pain or anxiety during emergence causes

hyperventilation and acute respiratory alkalemia

 Excessive mechanical ventilation also generates

respiratory alkalemia, especially if hypothermia or
paralysis has decreased CO2 production

 Acute respiratory alkalemia can generate confusion,

dizziness, atrial dysrhythmias, and abnormal cardiac
conduction
 Cont….
 Treatment necessitates reducing alveolar ventilation, usually
by administering analgesics and sedatives for pain and
anxiety
Metabolic Alkalemia
 Metabolic alkalemia is rare in PACU patients unless
vomiting, gastric suctioning, dehydration, alkaline
ingestion, or potassium-wasting diuretics caused an
alkalemia that existed before surgery

 Respiratory compensation through retention of CO2 is rapid

but limited because hypoventilation eventually causes
hypoxemia.
Glucose Disorders and Control

 Tightglucose control has been recommended to reduce

morbidity in a variety of postsurgical patients

 The control of glucose in diabetic and nondiabetic

patients has shown to reduce complications and hospital
length of stay and improve patient outcomes

 Urine glucose measurements should be reserved to

assess osmotic diuresis and estimate renal transport
thresholds by comparison with serum leve
 Hyperglycemia
 Glucose infusions and stress responses commonly elevate
serum glucose levels after surgery

 Moderate postoperative hyperglycemia (150 to 250 mg/dL)

resolves spontaneously and has little adverse effect in the
nondiabetic patient

 Type I diabetic patients are at risk for ketoacidosis

 Potassium replacement and serial blood glucose

determinations are essential.
 Hypoglycemia
 Hypoglycemia in the PACU can be caused by
endogenous insulin secretion or by excessive or
inadvertent insulin administration

 Either sedation or excessive sympathetic nervous system

activity masks signs and symptoms of hypoglycemia
after anesthesia.

 Diabetic patients and especially patients who have

received insulin therapy intraoperatively must have
serum glucose levels measured to avoid the serious
problems related to hypoglycemia.
Electrolyte Disorders
Hyponatremia
 Postoperative hyponatremia occurs if free water is infused
intravenously during surgery or if sodium-free irrigating
solution is absorbed during transurethral prostatic resection
or hysteroscopy

 Symptoms of moderate hyponatremia include agitation,

disorientation, visual disturbances, and nausea, whereas
severe hyponatremia causes unconsciousness, impaired
airway reflexes, and CNS irritability that progress to grand
mal seizures.

 Therapy includes intravenous normal saline and intravenous

furosemide to promote free water excretion
Hyperkalemia
 A high serum potassium level raises the suspicion of
spurious hyperkalemia from a hemolyzed specimen or
from sampling near an intravenous catheter containing
potassium or banked blood

 Postoperative hyperkalemia occurs after excessive

potassium infusion or in patients with renal failure or
malignant hyperthermia

 Treatment with intravenous insulin and glucose acutely

lowers potassium, whereas intravenous calcium counters
myocardial effects.
Hypothermia and Shivering
 During anesthesia, heat is redistributed and also is lost
by evaporation during skin preparation, by
humidification of dry gases in the airway, and by
radiation and convection from the skin and wound

 Temperature reduction is accelerated by cold

intravenous fluids and low ambient temperatures

 Rate of heat loss is similar during general or regional

anesthesia, but rewarming is slower after regional
anesthesia because residual vasodilation and paralysis
impede heat generation and retention
Cont….
 Many medications have been recommended to suppress
shivering, but meperidine is most efficacious in
conjunction rewarming.

 Fentanyl has also been used with patients in whom

meperidine is contraindicated.

 If temperature is near normal (>96 to 97°F) and

shivering is resolved, transfer from PACU to an
inpatient floor or a discharge area is acceptable.
Hyperthermia
 Hyperthermia is relatively uncommon in the PACU

 Elevated temperature might indicate a drug or

transfusion reaction

 High fever occurs with malignant hyperthermia, but

signs such as tachycardia, muscle rigidity, dysrhythmia,
hyperventilation, and acidemia establish the diagnosis
first.

 Ambient cooling, chest physiotherapy, incentive

spirometry, and antipyretics are usually sufficient to treat
postoperative fever
 NERVE INJURY
 Patient injuries due to surgical positioning can take many
forms, from end organ damage due to hypoxia or
hypotension to direct nerve injury due to compression or
traction.

 When considering positioning injuries, it is important to be

aware of patients who are at higher risk.

 Patients at increased risk of positioning injuries, specifically

peripheral nerve injury, include obese patients and those
with diabetes, peripheral vascular disease, hereditary
peripheral neuropathy, or an anatomic variable (e.g.,
cervical rib).
CONT…….
 Ulnar nerve, brachial plexus, spinal cord, and lumbo
sacral nerve root injuries were the major categories of
nerve injury resulting in a medical liability claim against
an anesthetist.

 Supine position risks

 The supine position, the most commonly used position
for all surgical procedures, is generally the safest
position and not associated with dramatic or catastrophic
positioning injuries
 Cont……..
 Even this position can lead to postoperative ulnar
neuropathy, the most common position-related nerve injury.

 Ulnar neuropathy accounts for approximately one third of

post-positioning nerve injuries and is more common in men.

 Thelarger tubercle of the ulnar coronoid process in men

may compromise the resistance of the ulnar nerve to injury.

 Pronation of the forearm exerts more pressure on the ulnar

nerve, while supination decreases pressure.
 Summary
Emergence and post operative issue in anesthesia is
inseparable idea which based in hospital of urgent cases
proper and well organized evaluation of the sign and stage of
anesthesia during emergence is very critical for better patient
recovery
The post operative planning beings with the preoperative
evaluation and formation of an introperative anesthesia plan,
the type of anesthesia(inhalation technique, total intravenous
anesthetic, sedation, local and regional) influence the type
and length of post anesthesia care unit (PACU) recovery.
the level of post anesthesia care unit depends on the
type/approach of surgery ,type of anesthesia ,introperative
course of events as well as patient, pre existing and envolving
comorbedities
Summary…..
The transfer of care to a PACU nurse include assuring that the
patient has had appropriate monitoring applied , admission vital
signs were taken a direct and through report received that
allows for Rapid evaluation should complication arise, as well
as a nurse capable handling the acuity of the patients medical
/surgical problems.

post anesthetic analgesia should be individualized to requirement

expectations. a multi modal approach includes the appropriate
use of non steroidal anti inflammatory drugs, narcotics , regional
and local anesthesia.
Discharge criteria should be tailored to the individual patient
underlying disease, recovery course and post discharge level of
care.
 References
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anesthesia- related incidents, events, and complications on postanesthesia care unit
utilization. Anesthiology .Analg 1999
 Cohen MM, O'Brien-Pallas LL, Copplestone : Nursing workload associated with
adverse events in the postanesthesia care unit. Anesthesiology 1999
 Hines R, Barash PG, Watrous G : Complications occurring in the postanesthesia care
unit: A survey. 1992
 Mackintosh C. (2007 ) Assesment and management of patients with post operative
pain. Date Of acceptance September 3.2007
 Maysoon S.Abdalrahim (2009 ) post operative pain assessment and management
Goteborg
 Ronald D. miller (2010 ) Miller’s anesthesia 7th edition . volume 2
 SA Jayrajh (2013 ) Postoperative Tracheal Extubation: Current Controversies . 14 June
2013 No
 Organisation W. Analgesic Ladder. World Health Organization; 1986.
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