Transcript Theatre Recovery

Principles of Recovery
Dr James F Peerless
August 2014
Objectives
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Principles of recovery
Overview
Handover
Pain scores
Discharge criteria
Day Surgery
Overview
What is Recovery?
• Specially designated area to recover patients
following procedures adjacent to theatres
• Run by a dedicated team of nurses and
ODPs
• Guidelines exist to ensure patient safety and
recognised standards of care
• There need to be roughly twice the number of
bays than theatres.
• Provision for overflow from ITU/Resus in
MAJAX
Recovery
General
• Scavenging
• Difficult airway trolley
• Available anaesthetist
• Emergency call system
• Drugs
Each bay
• piped oxygen, suction and air.
• Monitoring equipment
– including some invasive monitoring equipment
PACU
• High standards of monitoring to be maintained until
the patient is fully recovered from anaesthesia. Clinical
observations must be supplemented by the following
monitoring devices:
– Pulse oximeter
– NIBP
• The The following must also be immediately available:
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Electrocardiograph
Nerve stimulator
Means of measuring temperature
Capnograph
Recovery Standards
• After general or regional anaesthesia, all patients
should be recovered in a specially designated area
• The anaesthetist must formally hand over the care of a patient to
an appropriately trained and registered PACU practitioner.
• Written criteria for discharge of patients from the PACU should be
in place
• All patients must be observed on a one-to-one basis by an
anaesthetist or registered PACU practitioner until they:
– have control of their airway
– have stable cardiovascular and respiratory systems
– are awake and able to communicate.
• All standards should be applied to all areas in which patients
recover after anaesthesia, to include:
– anaesthetics given for obstetric, cardiology, imaging and dental
procedures, and in psychiatric units.
Handover
Handover
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Name
Age
Relevant medical history
Allergies and drug history
Procedure
Type of anaesthetic given
Analgesia, Local Infiltration and antiemetics
given
• IV Fluids used and Prescribed
• Any untoward events during Surgery and
Anaesthesia
• Post-operative instructions
Post-operative Pain
Pain Scores
• Remember that pain is subjective
• Simple numerical rating pain scores
– 0-10
• 4-6 (moderate), 7-10 (severe)
– 1,2,3
• Visual analogue scale
• FACES
Discharging from PACU
Discharge Criteria
General
• Patients to stay a minimum of 20 minutes
• Maintain 8+ on SALIM score
• Vital signs within normal limits for the patient
• T 36 or above
Systems
• Cardiovascular stability
• 10 < RR <24
• UO satisfactory
Discharge Criteria
Surgical
• Normal wound haemostasis, drain and wound sites
satisfactory
• Reversed from effects of anaesthesia (SALIM 8+)
Analgesia and Nausea
• Pain score <5
• Not agitated
• No PONV
• At least one set of observations with PCA/epidural
operational
• Appropriate plans for further fluids and analgesia
SALIM
3
2
1
0
AIRWAY
COUGH OR CRY
MAINTAINS
CLEAR AIRWAY
WITHOUT
HOLDING THE
JAW
HOLDING OF JAW HOLDING OF JAW
IS REQUIRED
AND OTHER
ADJUNCTS
REQUIRED
BEHAVIOUR
ABLE TO LIFT
HEAD
CAN OPEN EYES
AND SHOW
TONGUE
SOME NONPURPOSEFUL
MOVEMENTS
NO MOVEMENTS
CONSCIOUSNESS
PATIENT FULLY
AWAKE AND
ORIENTED
AWAKE BUT
NEEDS SUPPORT
RESPONDS ONLY
TO STIMULI
UNRESPONSIVE
Common Issues in PACU
• Pain
• PONV
• Other
– Altered GCS: Reduced LoC, Agitation
– Cardiovascular: Hypotension, ACS
– Respiratory: Failure, Hypoxia
Day Surgery
Day Surgery
• Increasing complexity of day-case procedures
• Wider range of patients deemed suitable for
day-case surgery
• Anaesthetists need to adopt techniques which
allow rapid recovery of the patient, whilst
minimising stress and discomfort.
Day-case Recovery
• Initial Phase
– as per Theatre PACU
– awake, protective reflexes have returned and pain is
controlled
• Second Phase
– Transfer to a day ward
– Further recovery and observation of common postoperative problems and emergencies
– Nurse-led protocol-based discharge
• Late Recovery
Discharge Instructions
• 24 hours post GA:
– Dot not drink EtOH, operate heavy machinery,
drive
• Require a supply of adequate post-procedure
analgesia suitable to the type of operation
• Protocol-driven: patients discharged once
criteria met.
Discharge Criteria
• Vital signs stable
• Orientated to time, place &
person
• Passed urine (if applicable)
• Able to dress & walk (where
appropriate)
• Oral fluids tolerated (if
applicable)
• Minimal pain
• Minimal bleeding
• Minimal nausea ⁄ vomiting
• Responsible escort present
• Has carer for 24-h post op
• Written & verbal post op
instructions
• Knows who to contact in an
emergency
• Dressings supplied
• Patient copy of GP letter
• Sick certificate
• Has take home medication
Discharge Medication
Discharge Medication
Summary
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Principles of recovery
Overview
Handover
Pain scores
Discharge criteria
Day Surgery