POSTANESTHESIA RECOVERY
From Survey of Current Issues in Surgical Anesthesia, sponsored by the Division of Anesthesiology, Critical Care
Medicine, and Comprehensive Pain Management, Cleveland Clinic Foundation, Cleveland OH
| PEDIATRIC ISSUES IN THE POSTANESTHESIA CARE UNIT (PACU) — Emad Mossad, MD, PhD, Vice Chair, Department
of Pediatric Anesthesia, Cleveland Clinic, Cleveland, OH
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| Geography: must be easily accessible and safe for patient; speaker’s institution set up in half-circle configuration; secretary
and nurses easily access various points and beds in PACU; nurses assist each other in covering patients; families and
children enter and exit through play area located outside PACU
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| Staffing: personnel affiliated with PACU also important; energetic, friendly, willing-to-help staff makes difference in
success of recovery room; if practice not purely pediatric, specific nurses should be trained for cross coverage; number of
PACU beds, compared to operating rooms, varies; 2:1 ratio most common, especially with ambulatory procedures; ratio
of patients to nurses depends on age of patient and type of procedure; during phase I recovery, 2:1 ratio most common
(one nurse for every 2 beds; changes if child <1 yr of age, during critical procedure, or if patient in critical condition); 3:1
ratio in phase II recovery; minimum monitoring includes heart rate and saturation; specific admission and discharge criteria
necessary for recovery room success, especially for phases I and II recovery; modified Aldrete scoring most commonly
used discharge criteria; score ≥12, absence of bleeding, and adequate pain control necessary before discharge from
phase I to phase II recovery, and from phase II recovery to home or hospital floor; CARS mnemonic for discharging child
from recovery (consciousness and circulation, activity or movement to prevent skin injury, respiration, and saturation);
patient must fulfill CARS criteria before discharge from phase I to phase II recovery
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| Perioperative recovery room complications: more common in infants than in older children; less common following
emergency operations, compared to scheduled procedures; respiratory complications most frequent intraoperatively,
followed by cardiovascular complications; American Society of Anesthesiologists (ASA) classification of
physical status correlates with frequency of complications in postoperative period; major complications (eg, cardiac arrest,
cardiovascular problems) have decreased significantly with better anesthetic care
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 | Postoperative nausea and vomiting (PONV): most common postoperative complication in children in PACU; peak incidence
in children 8 to 11 yr of age; duration of surgery does not increase risk for PONV; patient or family history of
motion sickness increases risk; most common after head-and-neck surgery (not after abdominal surgery); rare in child
<2 yr of age; increases with age; particular anesthetic used also increases risk for PONV; receptors blocked by antiemetics
include dopaminergic, muscarinic, histaminergic, steroid, and serotonin; prevention and treatment—
dexamethasone (Decadron) more commonly used in children than in adults to treat PONV (0.5 mg/kg given intravenously
[IV] most common dose used in children for prevention or treatment); study looking at efficacy of ondansetron,
droperidol, and metoclopramide showed better effect with ondansetron than with other 2 medications; similar complication
rates; ondansetron most commonly used medication in children for treatment or prophylaxis; effective even
when opioids used; superhydration frequently used in children to prevent PONV (30 mL/kg crystalloid intraoperatively)
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| Emergence delirium (ED) and pain: definition unclear (child who awakens crying, or child who is completely inconsolable);
incidence varies significantly; risk and impact on care varies depending on definition; interventions differ
depending on symptoms treated and method of treatment; reported incidence of inconsolabilty in children ≈20%, compared
to ≈5% in adults; highest incidence in younger children; in one study, 52% of children could not be comforted
without use of pharmacologic intervention; prolongs recovery and imposes risk for injury to child, parents, and caregivers;
most common at-risk groups of children include those <3 yr of age, child coming to surgery for first time, child
with poor adaptability (requires significant preoperative medications), child undergoing head-and-neck surgery (most
commonly associated with ED in children), and child in whom short-acting (<14 min) agents used; unknown if child
wakes up in pain or if child suddenly wakes up in unfamiliar environment and then has ED (with or without pain); in
study of children undergoing magnetic resonance imaging (MRI; ie, painless procedure), sevoflurane (used as baseline
anesthetic) associated with higher incidence of ED than halothane; duration of agitation and duration of stay in PACU
not significantly different; another study comparing sevoflurane to propofol found incidence of ED dissimilar (≈5-fold
higher with sevoflurane); combination of pain and rapid emergence implicated in ED
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| Decreasing incidence of ED: avoid short-acting maintenance anesthetics; supplement anesthetic with medication of
longer duration; use benzodiazepines (oral or intranasal) preoperatively; provide adequate pain control (supplement
anesthetic with regional anesthesia); use newer anesthetic agents
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| Treating pain: intranasal fentanyl (1-2 µg/kg) effective in erratic child who will not take oral premedication; onset of action
<10 sec; duration of action ≤15 min; however, vomiting risk and home emesis increase; options for pain treatment
at end of surgery or in PACU include IV fentanyl, acetaminophen (oral or rectal), ketorolac (oral or IV), and oxycodone
(oral); supplementing anesthetic with caudal anesthesia can decrease incidence of ED significantly; new α1 and
α2 adrenal receptor agonists can be used as supplements to decrease incidence of ED in children and adults; α2 agonists
have minimal respiratory depression, decrease anesthetic requirements, decrease analgesic requirements postoperatively,
help in blood pressure control, and have anxiolytic and sedative effects; study shows use of IV clonidine
significantly decreases incidence of ED, compared to placebo, in head-and-neck procedures; duration in PACU “didn’t
change as much,” but time to arousal may be prolonged slightly; clonidine also effective when used caudally; dexmedetomidine
has sedative, analgesic, and anxiolytic effects; decreases concentration of norepinephrine in circulation;
given in dose of 1 µg/kg over 10 min; requires mixing and infusion; onset of action 5 min, duration of action 60 to 75
min (compared to 3-6 hr with clonidine); study found incidence of ED decreased significantly with dexmedetomidine;
discharge from PACU shortened
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| ORTHOPEDIC ISSUES IN THE PACU — John E. Tetzlaff, MD, Professor of Anesthesiology, Cleveland Clinic Lerner
College of Medicine of Case Western Reserve University, and Director, Center for Anesthesiology Education, Division of
Anesthesiology, Critical Care Medicine, and Comprehensive Pain Management, Cleveland Clinic, Cleveland, OH
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| General considerations: increasing percentage of orthopedic patients seen in ambulatory setting; prescreened electronically
in speaker’s institution (most are extremely healthy and low risk); not seen by anesthesia provider until ≈30 min
before being anesthetized; “greatly liberalized” npo guidelines (in healthy patient, clear liquids up to 4 hr before anesthesia
results in patient with less in stomach); perioperative antibiotics delivered within 1 hr prior to incision; stress-dose steroids
given when necessary (hydrocortisone 300 mg/day; equivalent to adrenal output under maximum conditions); with
joint replacement and spine cases, blood transfusion may be necessary (type and cross-match needed); speaker stops coumadin
therapy for 5 days prior to surgery
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| Medical clearance: complicated (sedentary lifestyle increases “level of interest” in invasive or stress-type testing of
heart and lungs); functional status more important than chronologic age; as patient becomes less active secondary to destruction
of joints or disease in lumbar spine, association of comorbidity with orthopedic disease high; propensity for coronary
artery disease and hypertension higher; patient may not be active enough for symptoms to manifest; less interest in
preoperative assessment in advance; patient may be seen afternoon before day of surgery, even for complex cases; documentation
“interesting and challenging”; obtaining informed consent may get “crammed into a very short interval” prior
to surgery
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| NPO status: new criteria apply to healthy patients; pain, diabetes (especially insulin dependent), morbid obesity, and
trauma are exceptions to npo rule; functional status also influences decision; extremely sedentary person may have delayed
gastric emptying; ask about symptoms consistent with gastrointestinal (GI) upset or reflux
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| Antibiotics: surgeon decides what antibiotics should be given; anesthesia provider becomes more insistent with need for
prevention of subacute bacterial endocarditis; some procedures (eg, airway management, especially insertion of laryngeal
mask airway [LMA] or direct laryngoscopy) associated with bacteremia; antibiotic intervention should be completed or
underway when these events occur; may help surgeon with intraoperative cultures; treat reactions to antibiotics; deal with
various opinions about penicillin allergies and cross-reactivity with other antibiotics (default usually from cephalosporin
to vancomycin); administer vancomycin only on pump; limit use to setting where patient directly attended with either intermittent
or continuous vital signs; risk for hypotension associated with rapid infusion of vancomycin from histamine release;
stress-dose steroids for rheumatoid patient, mixed connective tissue, ankylosing spondylitis (to suppress
progression of disease), and transplantation; long-term steroid use causes subcutaneous tissue to become more fragile;
tensile strength of skin greatly reduced, especially in rheumatoid patient; adhesive tape and other devices to secure airway
and other tubes potentially traumatic (especially patient’s eyes)
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| Blood loss: surgeon’s order necessary for blood, but anesthesia provider often helpful; for certain procedures, eg, primary
total knee, >50% of autologous blood harvested discarded; cell salvage most likely to replace autologous blood in future;
nonsteroidal anti-inflammatory drugs not problematic for either surgery or regional anesthesia unless patient symptomatic;
withdrawal for 24 hr eliminates most risk; aspirin more problematic; larger doses (eg, 325 mg qid) cause permanent
“salicylation” of platelets and potentially large blood loss; smaller doses (1 aspirin or baby aspirin per day) not contraindicated
for either surgery or regional anesthesia; residual heparin effect may cause problems (even more serious with low
molecular weight heparin [LMWH; enoxaparin (Lovenox)]); must be withdrawn for ≥12 hr; in procedure done while patient
receiving LMWH or if LMWH given while epidural in place, “it needs to be held for a period of time” before catheter
can be removed; if possible, avoid overlap of LMWH and indwelling neuraxial catheter; speaker less enthused for
elective surgery and regional anesthesia in coagulopathic patient
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| Issues unique to orthopedics
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| Blood: large amount of blood loss may be detected only upon arrival in PACU (due to use of pneumatic tourniquet); with
bilateral knee replacement, majority of blood loss occurs in PACU; combination of bleeding in PACU and autonomic
instability during recovery from spinal or epidural can be associated with some problems; 8% to 10% of bilateral knee
replacements have critical incident, invariably related either to blood loss or volume status; hemodilution has impact as
volume shifts from plasma space to third space; clear volume expansion given at beginning of orthopedic surgery;
blood loss remains equal, but amount of red blood cells lost per unit decreases; autologous blood more likely to be used
than heterologous blood; wound-salvaged blood exposed to procoagulant, so salvage rate low (at most, only one-third
of cells lost)
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| Pain: knee replacement extremely painful; intraoperative opioids used with general anesthesia, but limited usefulness as
total pain control postoperatively; central axis blocks can be maintained; low doses of neuraxial morphine also useful
(serious side effects of respiratory depression, pruritus, and urinary retention low); some enthusiasm for epidural, slow-
release morphine, but occasional massive discharges can occur; anxiolytics may be effective for acute pain in orthopedics
(anxiety synergistic with nociception; anxiolysis good supplement to analgesia); if upper and lower extremity pain
treated progressively with constantly more opiates, and condition progressively worsens, possibility pain has shifted
from somatic to ischemic; if ischemic pain comes from compartment syndrome, limited period of time for recognition
before permanent damage occurs; compartment syndrome of forearm or lower leg disabling events if they continue on
to ischemia; extreme sudden onset of pain following spine surgery with instrumented fusion requires call to surgeon or
x-ray due to migration of devices; may impair nerve roots or impinge spinal cord; consider possibility of onset of epidural
hematoma in patient recovering from block, especially with sudden pain; diagnosis with magnetic resonance imaging
(MRI) or computed tomography (CT); treat with decompression; high probability of achieving good outcome if
recognition occurs within 12 hr of symptoms (low probability if it occurs 24 hr after onset)
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| Recovery: peripheral and plexus blocks may be problematic in PACU (depends on whether upper or lower extremity);
most are comfortable with “anesthetic limb,” with evidence showing functioning brachial plexus; more problematic
with central and lower-extremity blocks (patient must be upright; increased possibility for elderly patient on crutches
to fall); demonstration of ability to void required prior to release; with certain types of regional anesthetic procedures
(eg, supraclavicular block, transarterial technique), recovery necessary to detect complications before discharge (eg,
pneumothorax, hematoma); orthopedic surgeon often transfers responsibilities to anesthesia provider; in speaker’s institution,
anesthesia providers place lines and verify correct placement before releasing from PACU; surgeon “will
want to see that” fractures properly reduced, plates still in place, prostheses connected, no acute dislocation, and rods
in spine placed correctly; continuous passive motion (CPM) machine used with joint surface injury and joint replacement;
create acute postoperative pain; local anesthetic conduction block (peripheral or central) necessary to prevent
pain; absence of neuraxial block prolongs recovery (difficult to adjust use of morphine to tolerate device)
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| Critical incidents: pulmonary embolism (clots may be forming during procedure itself; seen in PACU in small percentage
of patients); acute dislocation of joints (commonly hip; associated with movement adduction of leg); epidural hematoma
(associated with neuraxial anesthesia [uncommon] or spine surgery); disseminated intravascular coagulation
(DIC; typically in lower-extremity revision joint surgery with infection)
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Suggested Reading
Aldrete JA et al: A postanesthetic recovery score. Anesth Analg 49:924, 1970; Cohen IT et al: Rapid emergence
does not explain agitation following sevoflurane anaesthesia in infants and children: a comparison with propofol. Paediatr
Anaesth 13:63, 2003; Cravero J et al: Emergence agitation in paediatric patients after sevoflurane anaesthesia and no
surgery: a comparison with halothane. Paediatr Anaesth 10:419, 2000; Finkel JC et al: The effect of intranasal fentanyl
on the emergence characteristics after sevoflurane anesthesia in children undergoing surgery for bilateral myringotomy tube
placement. Anesth Analg 92:1164, 2001; Isik B et al: Dexmedetomidine decreases emergence agitation in pediatric patients
after sevoflurane anesthesia without surgery. Paediatr Anaesth 16:748, 2006; Erratum in: Paediatr Anaesth 16:811,
2006; Jorgensen LN et al: Antithrombotic efficacy of continuous extradural analgesia after knee replacement. Br J Anaesth
66:8, 1991; Kalkman CJ et al: Differential effects of propofol and nitrous oxide on posterior tibial nerve somatosensory
cortical evoked potentials during alfentanil anaesthesia. Br J Anaesth 66:483, 1991; Kavuri S et al: Low-dose
intrathecal-meperidine for lower limb orthopaedic surgery. Can J Anaesth 37:947, 1990; Erratum in: Can J Anaesth 38:263,
1991; McQueen DA et al: A comparison of epidural and non-epidural anesthesia and analgesia in total hip or knee arthroplasty
patients. Orthopedics 15:169, 1992; Milligan KR et al: The characteristics of analgesic requirements following
subarachnoid diamorphine in patients undergoing total hip replacement. Reg Anesth 18:114, 1993; Sharrock NE et
al: Haemodynamic effects and outcome analysis of hypotensive extradural anaesthesia in controlled hypertensive patients
undergoing total hip arthroplasty. Br J Anaesth 67:17, 1991; Sharrock NE et al: Hemodynamic response to low-dose
epinephrine infusion during hypotensive epidural anesthesia for total hip replacement. Reg Anesth 15:295, 1990; Tempelhoff
R et al: Is the "kneeling" prone position as dangerous as the sitting position for the development of venous air embolism?
Anesth Analg 75:467, 1992; Weldon BC et al: The effect of caudal analgesia on emergence agitation in children
after sevoflurane versus halothane anesthesia. Anesth Analg 98:321, 2004.
Educational Objectives
| The goal of this program is to improve the anesthetic management of both the pediatric patient and the orthopedic patient
in the postanesthesia care unit (PACU). After hearing and assimilating this program, the participant will be better
able to:
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| 1. Demonstrate the importance of staffing in the care of children.
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| 2. Summarize common perioperative recovery room complications in children.
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| 3. Outline the management of emergence delirium and pain in the pediatric patient.
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| 4. Discuss the anesthetic care of patients for orthopedic surgery.
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| 5. Review common issues in the PACU for orthopedic surgery and formulate a plan for dealing with these issues.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified
conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business
or commercial interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Drs. Mossad and Tetzlaff spoke at Survey of Current Issues in Surgical Anesthesia, held November 11-15, 2006, in Naples,
FL, and sponsored by the Division of Anesthesiology, Critical Care Medicine, and Comprehensive Pain Management,
Cleveland Clinic, Cleveland, OH. The Audio-Digest Foundation thanks the speakers and the Cleveland Clinic for their cooperation
in the production of this program.
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