Risk modification in the postanesthesia care unit

By taking an organized approach to problem-solving in the PACU, as part of an overall hospital-mandated quality assurance program, PACU staff can increase patient safety, reduce risk, and improve the quality of care.     

Predictive factors of early morphine requirements in the post-anaesthesia care unit (PACU)

Use of morphine by titration in the post-anaesthesia care unit(PACU) is often the first step in postoperative pain management.This approach provides rapid analgesia but shows a wide inter-individualvariability in morphine requirements and may prolong patientstay in the PACU. The aim of this study was to identify thepatient characteristics, surgical, anaesthetic, and postoperativefactors predictive of early morphine requirements. The studyincluded 149 patients undergoing various non-cardiac surgicalprocedures under general anaesthesia. In the multiple regressionanalysis of nine variables, only ethnicity (Caucasian), emergencysurgery, major surgery, surgery exceeding 100 min, and painscore on arrival in PACU were predictive factors of morphinerequirements. This observational study identifies for the firsttime independent predictive factors of morphine requirementsin the early postoperative period. Future studies are warrantedto evaluate the impact of intervention on these factors andany resulting improvement in postoperative pain treatment. Br J Anaesth 2001; 87: 385–9     

Thrombosis of sirolimus-eluting coronary stent in the postanesthesia care unit

A 44-yr-old woman with a drug-eluting coronary stent placement two weeks before surgery suffered a myocardial infarction in the postanesthesia care unit immediately after hysterectomy. She had missed only one dose of aspirin and clopidogrel preoperatively. Early recognition of subacute stent thrombosis and urgent percutaneous coronary intervention probably prevented her death. In this case report, we highlight perioperative coronary stent issues and discuss their implications.     

老年患者全麻后麻醉恢复室发生低氧血症的危险因素

目的 探讨老年患者全麻后麻醉恢复室(PACU)内发生低氧血症的危险因素。方法选择2021年7月至2022年1月入PACU的全麻老年患者262例,男110例,女152例,年龄≥65岁,ASAⅠ—Ⅲ级。低氧血症定义为拔除气管导管或喉罩后30 min时的氧合指数≤300,根据PACU内是否发生低氧血症分为两组：低氧血症组和非低氧血症组。将单因素分析后P<0.1的指标纳入多因素Logistic回归分析,筛选老年患者全麻后PACU内发生低氧血症的危险因素。结果 有105例(40.1%)患者PACU内发生低氧血症。单因素分析显示,与非低氧血症组比较,低氧血症组年龄明显增大,手术时间明显延长,术中输液量和出血量明显增多,ASAⅢ级、合并高血压、术前SpO₂<95%、术前压疮风险评分11～17分、术前Caprini血栓风险评分≥5分、俯卧位、术中输血、术后入PACU体温<36℃的比例明显升高(P<0.1)。多因素Logistic回归分析显示,合并高血压(OR=3.475,95%CI 1.781～6.781,P<0.001)、术前SpO₂     

Trace nitrous oxide levels in the postanesthesia care unit.

The effect of trace levels of waste anesthetic gases on the health of postanesthesia care unit (PACU) nurses who work in an unscavenged environment has been questioned, although it seems likely that levels of trace gases in the PACU would be much lower than those in the operating room. In this study, we documented nitrous oxide levels in the ambient air of two large PACUs. Nitrous oxide levels were measured using a time-weighted average monitor worn by 33 PACU workers at two different hospitals for the duration of their shifts. On the same day, patient data were collected at the time of admission to the PACU. Data included age and weight of the patient, type of surgery, anesthetic technique, and end-tidal level of nitrous oxide immediately before the patient left the operating room. The mean time-weighted average nitrous oxide level in PACU A was 2.0 ppm (range 0-6.4); in PACU B, it was undetectable, i.e., < 2.0 ppm. Levels of nitrous oxide to which PACU patient care personnel are exposed are well below the National Institute of Occupational Safety and Health and Occupational Health and Safety Administration recommended exposure level of 25 ppm measured for the duration of anesthetic administration. Implications: Our results indicate that the levels of nitrous oxide in postanesthesia care units with well maintained, modern ventilation systems are very low. Previous research suggests that the health of workers exposed to these levels should not be adversely affected.     

Use of postanesthesia discharge criteria to reduce discharge delays for inpatients in the postanesthesia care unit

STUDY OBJECTIVE: To determine whether a set of predetermined discharge criteria, used by nurses, shortens the length of patient stay in the postanesthesia care unit (PACU) without compromising safety. STUDY DESIGN: Prospective clinical study. SETTING: Postoperative recovery area of a large, tertiary-care, academic hospital. PATIENTS: 1,198 adult, ASA physical status I, II, and III patients, 18 years or older, requiring general anesthesia. INTERVENTIONS: Two groups of inpatients were followed. In the first group, over a 90 day period, all inpatients meeting study inclusion criteria were discharged by a physician (traditional discharge group [TDG]). This period was followed by a subsequent 90 day period in which a second group of patients were discharged by a PACU nurse using predetermined discharge criteria (discharge criteria group [DCG]). MEASUREMENTS: Demographic and discharge variables, including the time when the physician was called for an order, the time a discharge order was written, and the actual discharge time, were recorded. Other comparisons of various discharge variables included the time that discharge criteria were met, the actual discharge time, and the difference between these times. The frequency of PACU stays longer than 60 minutes, PACU discharge delays, and the time discharge criteria were met longer than 60 minutes were also compared between groups. Floor nurse satisfaction with patient status and any related morbidities noted were also measured. MAIN RESULTS: Length of PACU stay was significantly shorter (133.1 +/- 91.4 vs 101.7 +/- 53.7 min; P < 0.05) for inpatients in the DCG group. Discharge delays were higher with physician discharge. The DCG had a lower number of patients with multiple delays. There was no significant difference in the occurrence of adverse events between the two groups. CONCLUSIONS: Predetermined discharge criteria resulted in a 24% decrease in PACU time.     

Myoclonic seizure in the postanesthesia care unit after thoracic laminectomy

IMPLICATIONS: We report a patient who developed myoclonic seizure in the postanesthesia care unit after thoracic laminectomy. Expeditious diagnostic evaluation of unrecognized dura tear during surgery must be instituted immediately to avoid untoward sequelae. Specific treatment in addition to supportive care is required if the diagnosis is to be clearly identified.     

Hypoxemia in the postanesthesia care unit: an observer study

To determine the incidence and duration of hypoxemia in the postanesthesia care unit (PACU), 200 patients were investigated in a single-blind observer study. The number of unrecognized hypoxemic episodes, as well as risk factors and possible association between hypoxemia and postoperative morbidity, were studied. Oxygenation was monitored continuously with a pulse oximeter. One or more hypoxemic episodes (SpO2 less than or equal to 90%) were noted in 55% of the patients. SpO2 values less than or equal to 80% were noted in 13% of the patients. Supplementary oxygen was given during 55% of the 447 hypoxemic episodes registered. The hypoxemic episodes were unrecognized by the staff in 95% of the cases. With stepwise multiple logistic regression analyses, risk factors associated with a higher incidence of hypoxemia were: duration of anesthesia (P less than 0.0001), age (P less than 0.002) and a history of smoking (P less than 0.01). Patients who had undergone regional anesthesia had a lower risk of hypoxemia (P less than 0.0002). The occurrence of hypoxemia in the PACU could not be correlated to postoperative morbidity. We conclude that hypoxemic episodes in our PACU are common and that the routine use of supplemental oxygen combined with normal clinical surveillance did not prevent hypoxemic episodes.     

Nursing workload associated with adverse events in the postanesthesia care unit

BACKGROUND: The authors used a nursing task inventory system to assess nursing resources for patients with and without adverse postoperative events in the postanesthesia care unit (PACU). METHODS: Over 3 months, 2,031 patients were observed, and each task/activity related to direct patient care was recorded and assigned points according to the Project Research in Nursing (PRN) workload system. PRN values for each patient were merged with data from an anesthesia database containing demographics, anesthesia technique, and postoperative adverse events. Mean and median PRN points were determined by age, sex, duration of procedure, and mode of anesthesia for patients with and without adverse events in the PACU. Three theoretical models were developed to determine the effect of differing rates of adverse events on the requirements for nurses in the PACU. RESULTS: The median workload (PRN points) per patient was 31.0 (25th-75th percentile, 25-46). Median workload was 26 points for patients with no postoperative events and 155 for > or = six adverse events. Workload varied by type of postoperative event (e.g., unanticipated admission to the intensive care unit, median workload = 95; critical respiratory event = 54; and nausea/vomiting = 33). Monitored anesthesia care or general anesthesia with spontaneous ventilation used less resources compared with general anesthesia with mechanical ventilation. Modeling various scenarios (controlling for types of patients) showed that adverse events increased the number of nursing personnel required in the PACU. CONCLUSIONS: Nursing care documentation based on requirements for individual patients demonstrates that the rate of postoperative adverse events affects the amount of nursing resources needed in the PACU.     

Complications occurring in the postanesthesia care unit: a survey.

To identify and quantitate complications occurring in the postanesthesia care unit (PACU), a prospective study evaluated 18,473 consecutive patients entering a PACU at a university teaching hospital. Using a standardized collection form, the incidence of intraoperative and PACU complications was determined. The combined PACU and intraoperative complication rate was 26.7%. Data showed a PACU complication rate of 23.7%, with an overall intraoperative complication rate of 5.1%. Nausea and vomiting (9.8%), the need for upper airway support (6.9%), and hypotension requiring treatment (2.7%) were the most frequently encountered PACU complications. Patients in whom PACU complications developed were analyzed by ASA physical status. Of all patients experiencing nausea and vomiting (n = 1571), the highest percentage were ASA physical status II patients (n = 831). Likewise, in the group of 1450 patients who demonstrated a need for upper airway support, 792 were ASA physical status II. In patients experiencing a major cardiovascular complication, for example, variables associated with a greater risk of developing any PACU complications were ASA physical status (status II), duration of anesthesia (2-4 h), anesthetic technique, emergency procedures, and certain types of surgical procedures (orthopedic or abdominal). For patients admitted with a temperature of less than 35 degrees C the duration of the PACU stay was 152 +/- 46 min compared with 116 +/- 65 min for patients with a temperature greater than or equal to 36 degrees C (P less than 0.01). In conclusion, events occurring during the PACU period continue to be a source of patient morbidity.     

Non-convulsive status epilepticus in the postanesthesia care unit following meningioma excision

Purpose

Non-convulsive status epilepticus (NCSE) is an underdiagnosed clinical entity in which electrical seizures occur with subtle or no overt clinical manifestations. It can cause delayed recovery from anesthesia and constitutes an important differential diagnosis for prolonged postoperative unconsciousness. This condition can be diagnosed only by electroencephalogram (EEG), and the institution of early treatment is associated with better prognosis. This case is presented to illustrate the occurrence of this rare clinical entity in a patient who had undergone extradural surgery.

Clinical features

An elderly female with no history of seizures or predisposing factors for convulsions underwent an uncomplicated left frontotemporal craniotomy for excision of an extradural meningioma. She was unresponsive following surgery, which could not be explained by the imaging and laboratory investigations. A subsequent EEG demonstrated periodic epileptiform discharges in lateralized left hemispheric distribution characteristic of seizures. The seizures were not effectively prevented by prophylactic fosphenytoin; however, the patient responded slowly to intravenous levetiracetam, which is known to be a more effective treatment for NCSE. The patient had no predisposing factors for the development of seizures and was undergoing an extradural surgery.

Conclusions

This case illustrates NCSE and emphasizes the importance of obtaining an electro-encephalogram early following craniotomy to diagnose any changes in the patient’s mental status. This case also emphasizes that institution of early treatment is important to assure better prognosis.     

腹腔镜下腹股沟疝修补术后尿潴留发生的危险因素分析

目的探讨腹腔镜下腹股沟疝修补术后尿潴留(postoperative urinary retention,POUR)发生的相关危险因素。方法回顾性地收集2010年1月至2015年5月行腹腔镜下腹股沟疝修补术的340例病人的临床资料。按照是否发生POUR将病人分为POUR和非POUR两组,比较组间病人年龄分布(50岁,≥50岁)、性别构成(男/女)、是否合并良性前列腺肥大、术前膀胱是否排空、是否术中留置导尿、术中补液量、手术时间及术后麻醉性镇痛药物使用情况等指标的差异,ROC及多元Logistic回归法分析相关指标与POUR发生的关系。结果组间病人性别构成、腹股沟疝情况、补片类型、术前是否排空膀胱、是否术中留置导尿、手术时间及术中补液量等指标相比差异无统计学意义(P均0.05),而POUR组病人50岁以上的高龄病人比例相对较大(P=0.016)、合并良性前列腺肥大病人比例相对较多(P0.001)、术后使用阿片类镇痛药物病人比例相对较大(P=0.001),组间差异均有统计学意义(P值均0.05)。单因素及多元回归分析结果显示,年龄≥50岁(OR=3.0,95%CI 1.3~6.9,P=0.01)、术后使用麻醉性镇痛药(OR=2.7,95%CI 1.2~6.1,P=0.01)是POUR发生的独立危险因素(OR值均1,P值均0.05)。结论年龄50岁的高龄病人及术后使用麻醉性镇痛药物可能是接受腹腔镜下腹股沟疝修补病人发生POUR的独立危险因素。     

Short-term noninvasive ventilation in the postanesthesia care unit: a case series

Eight patients suffering various causes of transient postoperative respiratory failure in the postanesthesia care unit were treated with short-term noninvasive pressure-support ventilation administered through a tight-fitting face mask. Intubation was avoided in all of them, and no complications were observed, as assessed by the treating anesthesiologist and from review of their charts. Indications and advantages of noninvasive ventilation in the early postoperative period are discussed.