Postoperative and recovery room care

In anaesthetic practice the patient is monitored closely and continuously from before induction and throughout the operative procedure. However, many problems associated with anaesthesia and surgery occur in the immediate postoperative period. The 2001 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report ‘Changing the way we operate’ stated, ‘Immediately after surgery all patients not returning to a special care area (e.g. ICU or HDU) need to be nursed by those trained and practiced in postoperative recovery.’

The anaesthetist retains responsibility for patients during their stay in the postanaesthesia care unit (PACU). With an effective handover they can delegate this responsibility to an appropriately trained and registered PACU practitioner; however, an anaesthetist should be immediately available to review the patient's care if required.

Professional bodies such as the RCoA and Association of Anaesthetists have made recommendations regarding the staffing, monitoring, care and discharge criteria for PACUs.

Staff

The core knowledge and competencies for staff in PACU are:

assessment and management of airway, breathing and circulation;
assessment of consciousness;
monitoring during the immediate postoperative phase;
i.v. access and fluid balance;
applied knowledge of pharmacology in perioperative care;
management of postoperative pain and postoperative nausea and vomiting (PONV); and
management of surgical and anaesthetic emergencies.

Each patient should receive one-to-one care from an appropriately trained member of staff until the patient has met the following criteria:

No requirement for any form of airway support
Breathing spontaneously
Haemodynamically stable and
Alert and responding to commands

To maintain this level of care, no fewer than two members of staff should be present in PACU whenever a patient does not meet discharge criteria.

All clinical staff in PACU should have an intermediate life support (ILS) or equivalent qualification, and should an anaesthetist not be immediately available, at least one staff member should be trained in advanced life support (ALS).

Although management of the airway (including simple adjuncts) is a core competency, many PACU staff are specifically trained in the management of patients with supraglottic airway devices (SAD) and their removal. Less commonly, training is extended to include management of tracheal tubes. However, the anaesthetist is responsible for ensuring that the staff member to whom they hand over is capable of taking over care of the patient. Because of the relatively high incidence of airway complications in PACU, a professional with suitably qualified airway skills should always be immediately available. Many units now provide an anaesthetist who is immediately available to attend PACU to enable timely anaesthetic intervention for patients without compromising the efficient running of ongoing operating lists.

After general, epidural or spinal anaesthesia, all patients should be transferred to a dedicated PACU for initial care unless admission to ICU is planned. It is important to recognise that not all high-dependency units (HDUs) are staffed with doctors and nurses with adequate skills in airway management.

Provision should be made for a member of the anaesthetic team to visit patients within 24 h after surgery when one or more of the following applies:

ASA physical status 3–5
Epidural analgesia is used on a general ward
Discharged from PACU with invasive monitoring or
Request by clinical staff

Facilities

All operating theatre complexes should have a dedicated PACU. Depending on the case load, two PACU beds per theatre are normally required to allow safe recovery of patients and discharge to the ward without delays to theatre schedules. Bed spaces should be adequate to allow unobstructed access for trolleys, x-ray equipment, resuscitation carts and clinical staff.

The principle is that staff members may look after the patient with all equipment and facilities to hand so that they can continue care without needing to leave the bedside. Each bed space should be fitted with 12 electrical socket outlets (six on each side of the bed), one oxygen and one medical air pipeline outlet, two vacuum outlets, an adjustable examination light, an emergency call system, physiological monitors with a display screen and a recording system for patient data. In addition, the PACU should have a fully equipped anaesthetic machine, a defibrillator, means of manual ventilation of a patient's lungs and a selection of airway adjuncts and devices. A comprehensive stock of drugs and equipment is essential, with staff available to deliver these to the bedside. Patient warming devices should be readily available to manage inadvertent perioperative hypothermia.

Patients continue to exhale volatile anaesthetic agents into the environment for some time after they are discontinued and so the ventilation in PACUs must be adequate.

Monitoring

Depending on the condition of the patient and the location of PACU in relation to the operating theatres, the period of transfer from theatre to PACU can be a time of increased risk. A brief interruption of monitoring may be acceptable if PACU is immediately adjacent to the operating theatre. However, where this is not the case, or if the patient is critically ill, appropriate mobile monitoring is required. Minimum monitoring standards ( Box 29.1 ) should be maintained until the patient has fully recovered from anaesthesia. This is to allow the rapid detection of airway, ventilatory and cardiovascular problems. Capnography aids the early detection of airway obstruction and should be used whenever a tracheal tube or SAD is in situ. Additional monitoring (e.g. invasive vascular pressures) may be indicated depending upon surgical, patient and anaesthetic factors and is at the discretion of the responsible anaesthetist in conjunction with the surgical and PACU teams.

Box 29.1

Minimum standards of monitoring

Minimum acceptable monitoring

Clinical observation (one-to-one)

Pulse oximetry

Non-invasive blood pressure

ECG

Core temperature

End-tidal carbon dioxide (if tracheal tube or supraglottic airway device in situ )

Additional monitoring which should be immediately available

Blood/capillary glucose

Nerve stimulator

Additional monitoring which should be available

Urine output

Invasive pressure monitoring (arterial line, central venous pressure)

Cardiac output monitoring

Access to haematological and biochemical investigations

A contemporaneous record of the measurements from monitoring should be kept and as a minimum should include:

conscious level;
patency of airway;
respiratory rate and adequacy of ventilation;
S p o ₂ and F io ₂ ;
BP;
heart rate and rhythm;
measure of pain intensity and PONV on an agreed scale;
any i.v. infusions or drugs administered; and
core temperature.

Where measured, additional variables such as urine output, central venous pressure, end-tidal CO ₂ and surgical drainage volume should also be recorded. The frequency of monitoring depends upon the stage of recovery, nature of the surgery and clinical condition of the patient.

Handover

It is essential that the anaesthetist formally hands over care of the patient to an appropriately qualified PACU practitioner. Handovers may be optimised through the use of standardised processes such as situation, background, assessment, recommendations (SBAR; an example is shown in Box 29.2 ) to improve their efficiency, accuracy and completeness. The use of checklists may further enhance the quality of handovers and ensure all relevant information is transferred.

Box 29.2

Example of PACU handover using SBAR (situation, background, assessment, recommendations)

Situation

Name

Age

Surgical procedure

Surgical complexities (e.g. bleeding)

Anaesthetic interventions

Anaesthetic complexities (e.g. airway difficulties, cardiorespiratory instability)

Critical events (e.g. significant haemorrhage)

Background

Medical history

Allergies

Relevant medications (steroids, cardiac medications, anticoagulants)

Usual functional preoperative state

Assessment

Anticipated ongoing problems

Current cardiorespiratory parameters

Recommendations

Management plan including analgesia, oxygen and i.v. fluids.

Investigations required and when

Destination after PACU

PACU, Postanaesthesia care unit.

All i.v. lines should be flushed by the anaesthetist to remove any residual drugs and to ensure patency before leaving a patient in PACU.

Postoperative planning

Each patient should have an individualised postanaesthesia care plan, which should be communicated in both written and verbal formats. The extent and detail will depend upon patient, surgical and anaesthetic factors but should be clear and easy to interpret.

Consideration should be given to:

the management of pre-existing disease;
the continuation, cessation or review of regular medications;
the need for and timing of investigations;
analgesic and fluid requirements;
the requirement for thromboprophylaxis, antibiotics and glycaemic control;
the frequency and nature of observations;
the appropriate level of postoperative care; and
prescription of oxygen, methods of administration and target S p o ₂ (if applicable).

Discharge from PACU

Whilst the responsibility for the safe and appropriate discharge of patients from PACU lies with the anaesthetist, the adoption of strict discharge criteria ( Table 29.1 ) enables this to be delegated to PACU staff.

Table 29.1

Association of Anaesthetists minimum PACU discharge criteria

A	Patient has a clear airway and protective airway reflexes.
B	Breathing and oxygenation are satisfactory. Oxygen therapy should be prescribed if appropriate.
C	The cardiovascular system is stable, with no unexplained cardiac irregularity or persistent bleeding. The specific values of pulse and blood pressure should approximate to normal preoperative values (or be at an acceptable level), ideally within parameters set by the anaesthetist, and peripheral perfusion should be adequate. Any i.v. cannulae should be patent, flushed if necessary, and i.v. fluids should be prescribed if appropriate.
D	The patient is fully conscious.
E	Pain and PONV should be adequately controlled and suitable analgesic and antiemetic regimens prescribed. Temperature should be within acceptable limits. All surgical catheters and drains should be checked.
Other	All health records should be complete and medical notes present.

i.v., Intravenous; PACU, postanaesthesia care unit; PONV, postoperative nausea and vomiting.

Patients who do not meet the agreed criteria, or who encounter problems during the recovery period, should remain in PACU and be reviewed by an anaesthetist to decide upon the appropriateness, timing and safety of discharge. Where necessary the patient may require admission to a higher level of care facility (e.g. HDU or ICU).

Levels of postoperative care

There are four recognised levels of postoperative care:

Level 0: Ward – basic observations.
Level 1: Enhanced ward – more frequent observations for patients at risk of deterioration or requiring basic resuscitation.
Level 2: HDU – detailed observation or intervention, and patients requiring single-organ support, excluding tracheal intubation/ventilation.
Level 3: ICU – complex patients requiring tracheal intubation/ventilation or support of more than one organ system.

Mechanisms for the early identification of patients requiring a higher level of care should be in place, as should the requirement for specialist postoperative intervention.

Several factors may result in the need for higher levels of care or specialist input in the postoperative period ( Table 29.2 ). There are a few absolute indicators for admission to HDU/ICU, but in most cases the decision is based on a combination of factors; early assessment of the patients by senior anaesthetists, followed by discussion with critical care staff, allows care to be offered on an individual basis.

Table 29.2

Factors implicated in the need for higher level or specialist postoperative care

Patient	Multiple or complex comorbidities Unstable or newly diagnosed disease Poor functional ability or acute functional decline Cognitive impairment
Surgical	Emergency surgery Prolonged surgery Major surgery (e.g. intra-abdominal, thoracic, vascular) Surgery associated with large fluid shifts Surgical complications or difficulties Specialist postoperative surgical requirements (e.g. cardiac, neurosurgery)
Anaesthetic	Airway complications or difficulties Respiratory or cardiovascular morbidity, complications or instability Reduced conscious level Metabolic derangement Sepsis Anaesthetic complications (anaphylaxis, aspiration) ASA ≥3
Global	Increased perioperative risk score Unexpected failure to meet PACU discharge criteria

ASA, American Society of Anesthesiologists physical status; PACU, postanaesthesia care unit.

Common early postoperative complications

Central nervous system

Many patients arrive in PACU with a depressed level of consciousness, ranging from mild disorientation to confusion, agitation, and coma. Usually this is attributable to the residual effects of anaesthetic, sedative, and analgesic medications but may be the result of pathological conditions or deranged physiology. The anaesthetist must be able to differentiate those causes that are benign and self-limiting from those that require investigation and intervention. Regardless of the precipitating cause, the effect on level of consciousness depends on the patient's premorbid condition and cognitive and physiological reserve.

Pathophysiology

Normal CNS function requires a controlled physiological environment. Anaesthesia and other acute or chronic pathological conditions may impair the homeostatic mechanisms responsible for maintaining CNS functions and result in a depressed level of consciousness. Physiological causes of a depressed consciousness level are shown in Table 29.3 . It is imperative that physiological derangements are promptly identified as they can cause irreversible CNS injury if not addressed.

Table 29.3

Physiological causes of altered consciousness

Respiratory	Hypoxia Hypercarbia
Metabolic	Acidaemia Hyperglycaemia
Energy substrate	Hypoglycaemia
Temperature	Hypothermia
Cerebral perfusion pressure	Hypotension
Biochemical	Hyponatraemia Uraemia Raised Ammonia

Investigation

Clinical examination and an extended arterial blood gas measurement should enable identification of a physiological cause for depressed consciousness level. Infection and sepsis, regardless of source location, may result in confusion, agitation, and depressed consciousness level. This may be due to the global physiological derangements that accompany the condition or a direct effect of infection on the CNS.

Physiological observation:
- HR, BP, S p o ₂
- Temperature
Extended arterial blood gas measurement
- Acid–base status
- P a o ₂ , P a co ₂
- Haemoglobin
- Sodium
- Lactate
- Glucose
Targeted investigation based on the patient's medical history
- Ammonia in liver failure
- Urea in renal failure

Drugs

A wide range of drugs used in anaesthetic practice result in depression of consciousness level, whether as an intended clinical effect or as an adverse effect, including:

volatile anaesthetics (particularly those with a high blood/gas solubility coefficient);
barbiturates;
benzodiazepines (e.g. midazolam, lorazepam);
α ₂ -agonists (e.g. clonidine);
antimuscarinics (e.g. atropine, hyoscine);
opioids;
antiemetics (e.g. droperidol, cyclizine);
local anaesthetics (e.g. systemic toxicity or total spinal anaesthesia); and
Neuromuscular blocking agents (NMBAs; e.g. postoperative residual neuromuscular block).

The extent of the effect on level of consciousness depends on the dose, timing and pharmacokinetic profile of the drug. To a degree the CNS effects of a drug may be predictable, but interpatient variability and the presence of acute or chronic pathological conditions may result in significant variation.

Pain

Pain is a potent stimulus to the CNS, but its effect on level of consciousness is complex. In the presence of inadequate analgesia it has the potential to speed recovery of conscious level but can also increase agitation in patients with depressed consciousness. Successful treatment of pain, such as with an effective regional anaesthetic technique, may cause a reduction in the conscious level if long-acting analgesic drugs have already been administered. Distension of the bladder or stomach may cause confusion or agitation or may be interpreted as such in patients who are unable to communicate effectively.

Cerebral pathological conditions

Consciousness may be impaired by functional or structural cerebral damage in the absence of global physiological derangement ( Table 29.4 ). A review of the patient's preoperative condition, surgical and anaesthetic course and clinical examination often aid the diagnosis. A high index of suspicion is essential, and rapid assessment, investigation and intervention may be required to avoid permanent cerebral damage.

Table 29.4

Pathological conditions resulting in altered consciousness

Pathological condition	Causes
Cerebral ischaemia/infarction	Profound or prolonged global hypoperfusion Profound or prolonged global hypoxia Emboli Thrombus Air Fat Disruption of cerebral blood supply Surgical (carotid surgery) Head positioning
Cerebral haemorrhage	Hypertension Trauma Intracranial surgery
Cerebral oedema	Alterations in osmotic balance Hyper- and hyponatraemia Hyperglycaemia Uraemia TURP syndrome Prolonged Trendelenburg position Trauma
Cerebral mass lesions	Tumour
Cerebral infection	Cerebral abscess Meningitis Encephalitis
Seizure	May be masked by neuromuscular blockade

TURP, Transurethral resection of the prostate.

Paediatric emergence delirium

Paediatric emergence delirium is most common in children aged 2–5 years and is discussed in detail in Chapter 33 . This is a different clinical entity to the delirium that may be seen after the use of ketamine, either for induction of anaesthesia or as analgesic agent (see Chapter 4 ).

Postoperative delirium

Age-related decline in cerebral and cerebrovascular function contributes to the relatively high prevalence of postoperative delirium (POD) and cognitive dysfunction experienced by older patients, which delays discharge and ongoing functional recovery. The process of identifying and reducing the risk of POD should begin preoperatively and continue into the postoperative period.

Postoperative delirium presents with acute, fluctuating confusion and disorganised thinking. Risk factors for the development of POD include:

age;
frailty;
cognitive impairment;
previous excessive alcohol or drug consumption;
cardiovascular and/or cerebrovascular disease; and
polypharmacy.

Early recognition should be communicated throughout the multidisciplinary care team and facilitate multimodal interventions aimed at reducing the prevalence, severity and/or duration of POD.

Recovery room delirium is a strong predictor for POD and so the recovery area can be an appropriate area for delirium testing. The National Institute for Health and Care Excellence (NICE) recommends that CAM-ICU (Confusion Assessment Method for the ICU) is used to diagnose delirium in PACU.

Patients should undergo evaluation for possible underlying triggers (e.g. hypoxaemia, sepsis, hypoglycaemia, or other physiological abnormalities), and these should be treated accordingly. A variety of environmental, supportive and pharmacological interventions may be of value in managing POD:

Basic steps such as orientation of the patient with their environment, adequate lighting, access to hearing aids and spectacles, hydration, and analgesia are useful in preventing and treating delirium.
Pharmacological treatment of delirium is indicated to resolve a specific underlying cause (e.g. hypoglycaemia) or, after discussion with a senior clinician, for control of symptoms refractory to basic interventions. The butyrophenone haloperidol is commonly used (p.o., i.m., or i.v. administration).
Common drugs that may worsen delirium include opioids, benzodiazepines and steroids; therefore all patients who develop POD should undergo a thorough review of their medications.

Postoperative cognitive dysfunction

Postoperative cognitive dysfunction (POCD) can be usefully defined as a ‘long-term, possibly permanent, disabling deterioration in cognitive function following surgery’. The incidence of POCD is estimated to be 25% at 1 week and 10% at 3 months. In one study, further follow-up of the affected patients showed that the incidence of cognitive problems eventually fell towards that in matched controls, but 1% still had unresolved POCD 2 years after surgery.

The proposed causes of POCD include emboli, perioperative physiological disturbance and pre-existing cognitive impairment. A number of risk factors for POCD have been identified:

Early POCD
- Increasing age
- General anaesthesia
- Increasing duration of anaesthesia
- Respiratory complication
- Lower level of education
- Reoperation
- Postoperative infection
Prolonged POCD (months)
- Increasing age

Whilst regional anaesthesia does not appear to be superior to general anaesthesia in preventing prolonged POCD, it may reduce the risk of early POCD, with important implications for physical recovery, co-operation with postoperative therapy and duration of hospital stay.

Respiratory system

Airway obstruction

Obstruction of the upper airway often occurs during recovery from anaesthesia, and the recognition and management of airway compromise is a keystone of good anaesthetic practice. Partial obstruction of the airway is characterised by noisy ventilation, particularly on inspiration (stridor). As the obstruction increases, tracheal tug, indrawing of the supraclavicular areas and use of the accessory muscle of inspiration occur. Total obstruction is signalled by absent sounds of breathing and paradoxical movement of the chest wall and abdomen.

Blood, oral secretions or regurgitated gastric fluids that have accumulated in the pharynx should be aspirated and the patient placed in the recovery position to allow any further fluid to drain. This position should be considered for all unconscious patients who have undergone oropharyngeal surgery and for patients at risk of aspiration of gastric contents.

Airway obstruction caused by the tongue or by indrawing of the pharyngeal tissues may be alleviated by simple airway manoeuvres such as a chin-lift and/or jaw-thrust. In some patients it is necessary also to insert an oropharyngeal airway, although this may stimulate coughing, gagging and laryngospasm during the light planes of anaesthesia. A nasopharyngeal airway is often better tolerated, but there is a risk of causing haemorrhage from the nasopharyngeal mucosa. Occasionally, insertion of a SAD is necessary to maintain the airway until consciousness has returned fully; in extremis, tracheal intubation is required. There may be patient-specific problems; it may be difficult to maintain a patent airway in an unconscious patient with an oral, pharyngeal or laryngeal tumour.

Foreign bodies, such as dentures (particularly partial dentures) or throat packs, may cause airway obstruction. The National Patient Safety Agency (NPSA) have prescribed the standards for management of throat packs to reduce the incidence of their inadvertent retention.

Airway obstruction may result from haemorrhage after surgery to the neck, including thyroid, carotid and spinal surgery; the wound should be opened urgently and the haematoma drained. This may not relieve the obstruction if venous engorgement or tissue oedema are marked. Occasionally, tracheal collapse occurs after thyroidectomy in patients who have developed chondromalacia of the cartilaginous rings of the trachea caused by pressure from a large goitre. Inspiratory stridor may be present or there may be total obstruction during inspiration; the trachea must be reintubated immediately. Rarely, laryngeal obstruction occurs after thyroid surgery if both recurrent laryngeal nerves have been traumatised (see Chapter 39 ).

Obstructive sleep apnoea (OSA) occurs with the greatest frequency in the first 4 h after anaesthesia, and is more common and severe in patients who receive opioids for postoperative analgesia. Regional anaesthetic techniques are, therefore, often preferred, but do not completely ameliorate the risk. Patients with OSA should be monitored carefully in the postoperative period, preferably in HDU. Patients who normally use a CPAP mask to reduce apnoeic episodes should use the mask at night throughout the postoperative period. If untreated, OSA may produce profound transient, but repeated, decreases in arterial oxygenation to less than 75% (corresponding to a P a o ₂ <5 kPa). These repeated episodes of hypoxaemia may cause temporary, and possibly permanent, defects in cognitive function in older patients and can contribute to perioperative myocardial infarction (MI).

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