URPA

DR. CLAUDIA M. CALDERON

VILCHEZ
 RECOVERY
• Process by which patients must return to their
preoperative state and achieve the highest functional
level
suitable of which they are
capable. 1- Ventilation * Operating
spontaneous room

- Recover consciousness
--------• URPA
PHAS and stability
ES cardiopulmonar
y
Flo
3- Recover capacity
or
psycho-motor
 DEFINITION
Room intended to provide care
immediate postanesthetics to patients
who have undergone surgery or
diagnostic procedures or
therapeutics under general anesthesia,
regional anesthesia or deep sedation,
until discharge criteria are met
predefined.
GOALS
1. Point out the importance of post-anesthetic
 surveillance in a post-anesthetic recovery unit.

■ Explain the main structural and functional

characteristics of a post-anesthesia recovery
unit (PACU).
■ Mention and explain each of the parameters
considered in the Post Anesthetic Recovery
Score.

■ Indicate the complications that occurred during

the PACU.
 PHYSICAL
CHARACTERISTICS
PLATFORM

1) Location:
Close to the operating
room. Access to ICU
and diagnostic aids.
 PHYSICAL
CHARACTERISTICS
PLATFORM

2)Design: • 2 beds for every 4

• wide doors procedures in 24
• Lightning hours
• Efficient control • Open Room.
environmental • isolated room
• Each bed: oxygen • Materials area
• air and suction. • Central for
personnel
2 beds per operating room
 PHYSICAL
CHARACTERIS
TICS
EQUIPMENT

1. Equipment and
elements for airway
management and
ventilation:
i) Oxygen source ii)
Oxygen balloons iii)
Elements for oxygen
therapy
iv) Suction.
 PHYSICAL
EQUIPMENT
CHARACTERISTICS
2 . Equipment and elements for monitoring
i) Pulse oximeter :
ii) Equipment to evaluate blood pressure
iii) Thermometers
 PHYSICAL
CHARACTERISTICS
EQUIPMENT
4. Elements for managing a cardiorespiratory
emergency
 Trolley with a locking system
Content Review Checklist
Rigid resuscitation board
working laryngoscope
Replacement of batteries and bulb for laryngoscope
Macintosh Curved Intuvation Paddle (n.0 3 or 4)
Two #7 or #7.5 endotracheal tubes
Two endotracheal tubes No. 8 OR 8.5
intubation guide
Hydrophilic lubricant
Magyl Forceps I
Ant olii ncli able ventilation bag
O reservoir bag, for self-inflating bag
Extension for O socket,
Transparent facial mask No. 5
Guedell cannulas n.03 and 4
TABLE 1. Minimum desirable content of the Suction probe n.0 16 and 18
Suction system in the rooms (or in the car)
cardiac and pulmonary resuscitation cart O mask,
Stethoscope
Blood pressure cuff
elastic compressor
Two peripheral poisonous cables of the 18-20 G
central venous catheter
Two macro-dropper infusion systems
0.9% physiological saline 2000 MI
Adrenaline nil less 10 mg I
Atropine (3 mg)
Lidocaine (250 mg ।
Bicarbonate I 5D mEq
Calcium, at least 150 mg in 10% preparation
2 syringes. 5 and 10 m I
IV needles
Defibrillator monitor plugged into the mains
Defibrillator (shock at 200 J twice, and at 360 J 10 times)
conductive gel
Sedative drug (midazolam or propofol i
Monitoring electrodes (at least 5)
Tape, cloth or bandage, gauze
Pov solution i iodine donut
Gloves
 PHYSICAL
CHARACTERISTICS
EQUIPMENT

• 5. Medicines
for pain control and
other possible
complications
NSAIDs, opiates, local
anesthetics,
antiemetics.
 CHARACTERISTICS
FUNCTIONAL
STAFF: • Doctor :
V Made up of one or more
P Medical anesthesiologists
> Nursing • Coordinator of the
SRPA be a
• Nursing staff:
V Head nurse +
several assistants
V Provide in the first
instance to any
patient in the PACU
V The patient's
condition and type
of surgery
determines the
number of nurses
• Class 1:

a nurse for
three patients: and
And not
complicated and
u awake
n
And c And any patient
Class 2: o
n
s
c
i
o
u
 s
AND • not
complicated
a nurse for
two patients: / And
pediatric patient
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 •Class 3:

a nurse for
each patients:
V any patient
requiring life
support or with
complications

h there must be a second nurse

available if
necessary
 INFORMATION REQUIRED BY NURSING

Patient name and type of operation

Relevant aspects of the medical history (for example, heart disease, lung disease, allergies,
etc.)
Notable physical abnormalities
Catheters and drains
Type of anesthesia (general and/or regional)
Anesthetic drugs administered
Degree of anesthetic recovery (e.g. eye opening, cough, etc.)
Special problems that occurred during anesthesia or emergency (for example,
bronchospasm, etc.)
Requirements:
a. Oxygen therapy and saturation by minimum desired pulse oximeter
b. Liquids administered during your stay in the unit.
c. Analgesia
• Interaction with other services

BACUDE
SANCMR

LABORATORY IERAPLA
RHEpRATORY

Transfer of the patient from the ward

surgery to the PACU.
• The transfer of the stretcher is done when the patient
partially recovers his autonomic reflexes.
• Before transfer, the operating room nurse will inform
the SRPA staff
• The patient should be transferred to the PACU if he
remains stable, ventilating
properly
V The most recommended position during transport
is lateral decubitus.
• During transport, the face and chest should be
carefully observed.
 PATIENT ADMISSION
V Record vital signs: BP, - Identification of
HR, RR, SpO upon
2, patient, age,
admission and then every diagnosis and
15 min. surgical procedure
performed.
V Anesthesiologist will – Description and location of IV
provide a complete and
summarized report: catheters.
- Medicine administration.
– Intraoperative evolution.
– Nature of
surgical procedure.
– Liquid balance.
 Post Anesthetic Recovery
Score and Discharge Criteria
 Historical
Framework
P Reversing the anesthetic phenomenon is as fascinating as its induction.

Q Ideally, anesthesia should end soon after surgery is completed.

P Lack of unity of criteria made apparent the requirement to establish a

specific system that would indicate the condition of arrival of the
patient, their progress towards the recovery of reflexes and
consciousness and, above all, whether patients could be transferred to
the hospitalization area where care Nursing is less intense and where
assessment is less frequent.
 Recovery Score
Post Anesthetic (PRP)
In 1970 an attempt to measure and document the course of gradual
recovery from anesthesia was proposed and published as
Postanesthesia Recovery Score (PRP)
(Aldrete and Kroulik, 1970)”

* Activity
❖ Breathing
❖ Circulation
❖ Awareness
❖
 Activity
“As patients recover from the experience
anesthetic, they begin to move their limbs and head,
usually toward the side of the surgical incision, if it is
“It was not carried out on the midline.”

Able to move all 4 limbs voluntarily or under command 2

Able to move 2 limbs voluntarily or under command 1

Able to move 1 limb voluntarily or under command 0
 Breathing
“Restoring respiratory gas exchange to normal is an
essential step toward recovery”

Able to breathe deeply or cough freely

Dyspnea, limited breathing or Tachypnea
Apneic or on artificial respirator
 Circulati
on
“Alterations in blood pressure have been
chosen as the representative measure of this
complex function since this sign has been measured
before, during and after anesthesia

+-20% of preanesthetic level 2

+- 20- 49% of the preanesthetic level 1 +-50% of
the preanesthetic level 0
 Awareness
“Auditory stimulation is preferred to physical
stimulation and can also be repeated as many times as
necessary. The level of consciousness also affects the
rates of
activity and breathing

URPA 1
DEFINITION 3
GOALS 3
PHYSICAL CHARACTERISTICS 5
PHYSICAL CHARACTERISTICS 6
PHYSICAL CHARACTERISTICS 8
PHYSICAL CHARACTERISTICS 10
PHYSICAL CHARACTERISTICS 12
PHYSICAL CHARACTERISTICS 15
CHARACTERISTICS 16
FUNCTIONAL 16
Historical Framework 26
Activity 28
Breathing 29
Circulation 30
Awareness 31
Oxygen saturation 32
ALDRETTE SCALE 33
Limitations of PRP 35
PACU complications 43

Oxygen saturation
"In the past (Aldrete and Kroulik, 1970, the level of
oxygenation was evaluated with skin color (pink = 2, jaundice or
paleness = 1 and cyanosis = 0); the need for a more objective
measure was resolved with the use generalized pulse oximetry
Able to maintain saturation
oxygen greater than 92% in ambient air 2

Needs oxygen installation to

maintain O2 saturation greater than 90% 1

O2 saturation less than 90% even with O2 supplementation

ALDRETTE SCALE
• With 8 points (9 points
for other authors)
can discharge
patient. The ideal is 10
points.
Characteristics Points

Activity 2
Moves 4 limbs voluntarily or on command Moves 2 limbs 1
voluntarily or on command Unable to move limbs
0

Breathing Able to breathe deeply and cough freely Dyspnea or 2

limitation of breathing 1
Apnea 0

Circulation Blood pressure < 20% of preanesthetic level Blood 2

pressure 20-49% of preanesthetic level 1
Blood pressure 2 50% of pre-anterior level 0

Awareness 2
Fully awake Answers the call Does not respond 1
0

Arterial oxygen 2
saturation (SaO2) Maintains SaOa > 92% with ambient air Requires O to 1
maintain SaO 2 > 90% SaOs < 90% with supplemental Os
0
 Limitations of PRP
It does not consider the possibility of some clinical conditions
that warrant continued observation in the recovery room or
transfer of the patient to the intensive care unit. These are:
a) Cardiac arrhythmias that do not affect blood pressure.
b) Bleeding from the incision site
c) Uncontrollable severe pain
d) Nausea and persistent vomiting.

PRP Modifications for Patients

outpatient surgery
Patients receiving outpatient anesthesia go through three stages of recovery.
a) The immediate controlled phase in the PACU where they recover their reflexes and
improve their state of consciousness. When PRP is between 8-10, they can be
transferred to the next stage.
b) Recover coordination, balance and restore other functions in an intermediate unit
where patients can rest in reclining seats where vital signs are completely stabilized.
Nausea and vomiting, excessive pain and bleeding from surgery should be absent.
Patients should be able to void, dress themselves, and walk with minimal assistance.
c) Eventually complete recovery from anesthesia and its long-term effects may require
days and occasionally weeks for functions such as thinking, concentration, memory,
driving a car, climbing stairs, making the decision to write a check, and returning to
normal.

Postanesthesia Recovery Score for

Outpatient
1) The condition of the dressing that covers the wound: in case blood or
other fluid drained from the surgical wound is found.

2) Intensity of pain at the surgical wound or other related site should be

recognized before discharge: appropriate analgesic to relieve or
improve pain without producing drowsiness.

3) The ability to stand and ambulate : take care of themselves and attend
to their most basic functions such as going to the bathroom, dressing,
etc.

Postanesthesia Recovery Score for

Outpatient

4) Tolerance to the oral route is important for taking drugs

and being able to eat.
5) Able to urinate spontaneously: painkillers and muscle
relaxants can affect this function. In case of subarachnoid
or epidural anesthesia (lumbar or caudal) patients may be
unable to evacuate for some time even though they have
recovered their sensory and motor functions.

POST-ANESTHETIC RECOVERY SCALE

IN
OUTPATIENT:

• Patients with >= 9 points can

receive discharge.
Criterion Characteristics Points
Vital signs Stable vital signs for age and baseline
Blood pressure and pulse ± 20% of baseline 2
Blood pressure and pulse 20 - 40% of baseline 1
Blood pressure 3- 40% of baseline 0

Activity level The patient must be able to ambulate as before the

intervention
Steady pace, without getting dizzy or reaching the basal 2
levelNeed help 1
Unable to wander 0

Nausea and vomiting Nausea and vomiting should be minimal upon discharge
Minimal: treated effectively with IV medication 2
Moderate: treated effectively with oral medication 1
Severe: persists despite treatment 0

Pain Pain should be absent or minimal at discharge, controllable

orally.
Minimum 2
Moderate 1
Serious 0

Bleeding It must be within the expected losses in that type of

intervention.
Minimum: no dressing change required 2
Moderate: fewer dressing changes 1
Severe: more than three dressing changes 0
 SAFE GUIDELINES FOR DISCHARGE
AFTER OUTPATIENT SURGERY.

The patient's vital signs must have been stable for at least
one hour
THE PATIENT MUST BE:
- Oriented in space, time and place
- Able to accept orally administered fluids*
- Able to evacuate*
- Able to dress himself
- Able to walk without assistance

THE PATIENT CANNOT HAVE:

- Minimal nausea or vomiting
- excessive pain
- Bleeding
 OTHER SCALES OF
POST-RECOVERY
SPECIAL ANESTHETICS
 POST-OPERATIVE CARE IN
CHILDREN: STEWARD SCALE
STEWARD SCALE PTJE INIC END

CONSCIOUSNES Wakes up, cries Responds to stimuli Does not

S STATE respond

SYSTEM Breathe, cough

RESPIRATORY Shallow breathing
Apnea

MUSCLE Move 4 limbs without getting tired

ACTIVITY Moves 2 limbs
Does not move any limbs
PACU complications

POST ANESTHETIC RECOVERY UNIT

 VA obstruction
RESPIRATORY

( Cause: backward displacement of flaccid tongue \ ■ Pcts.

With residual effect of General Anesthesia
Obstruction ■ Drowsiness and partial abolition of vital reflexes
Pharyngeal Therapy:
•/Placement of Guedel cannula
(Oxygen therapy at P+ (with Ambu reservoir) J.
( Cause: VA reactivity x blood and pharyngeal secretions\
Therapeutics:
Laryngospasm {Previous measurements
VApplication of succinylcholine (10-20mg)
Orotracheal intubation
\< Emergency cricothyrotomy J.
(Queer
Bronchospasm Pcts with Antec. From Hyperreactivity THEY MAINTAIN their
treatment
Therapy:
inhaled bronchodilator
 Detects: Pulse oximetry (Sa02 < 90%)
Cause:
V Low Inspiratory Fi02
V Alterations in the ventilation/perfusion relationship BY:
■ Atelectasis
Hypoxemia ■ Pneumothorax
■ Cardiogenic pulmonary edema
■ Pulmonary embolism
Therapy:
VCorrect the causal agent
VRespiratory Physiotherapy
VChest drain placement
/Oxygen therapy

D alveolar ventilation A (PC02) in blood

Clinic: HR, HBP, sweat, drowsiness, PCO2
Cause:
VDepres. CR x residual effect of anesthesia or analgesics
Fx music VD Ans. BY:
■ Bad fx resp. Secondary to surgery
Hypoventilatio ■ Residual effect of muscle relaxants
n Therapy:
VAdm drugs reverse CR depressant effect
VAttenuate ventilation limiting factors
•Bronchodilator treatment.
 ( Cause: Decrease Preload
Decreased myocardial contractility
CIR CULATORIAS«,
Post load reduction
Therapy:
{Blood transfusion or saline administration
HYPOTENSION {Inotropic support with dopamine or ephedrine
' Administration of ephedrine in mild transient vasoplegia

HYPERTENSIO Cause: It is secondary to decompensation of previous HTN

N due to the presence of pain, hypercapnia, hypoxemia.
Therapy:
{ Dx cause trigger
VOxygen therapy, Bronchodilators, Diuretics
\ Antidepressant drug: Nitroglycerin_________)

( 7 1st order problem in Anesthetic Act

V Associated with alt.
■ Ionic or metabolic (hypokalemia, acidosis)
■ Predisposing Cardiac Pathology: Ischemia, hypertrophy
■ 70% arrhythmias bradycardia and tachycardia Pcts ASA I and
ARRHYTH
II
MIAS
Therapy:
■ Dx trigger cause
g Antiarrhythmic drugs.
 Delay in recovery
awareness

•Residual effects of
anesthetics

• Rule out: Metabolic

alterations Cerebral
vascular accident
 ( URPA 1st Magnitude Probl
> F: 2/3 PACU pain (Intensity: MS)---Lima 04/05/08
PAIN > Factors: Age, type of surgery, psychological preparation.
Therapy:
{Mild Pain: NSAIDs PO or minor opioids (Codeine)
{Moderate Pain: IV NSAIDs (Ketorolac, Metamizole)
\/ Severe Pain: Major iv opioids (Meperidine)

NAUSEA Most frequent complications observed in the PACU

VOMITING Therapy:
Prokinetic antiemetic drugs (metoclopramide 10 mg)

Cause:
IPOTERMI AG: Anesthetics increase the thermoregulatory threshold by
SHAKING 2.5 ªC, which determines that the thermogenic mechanisms of
heat loss (peripheral vasoconstriction) are not activated until a
temperature of 34.5 ªC is reached.
Therapy
Passive heating measures (insulation)
\ Active Measures: Thermal blankets or continuous warm air flow
THANK
YOU