Nurses care for postoperative patients in postanesthesia Phase I or postanesthesia Phase II, according to designations made by the American Society of Post Anesthesia Nurses (ASPAN). Nursing responsibilities during Phase I focus on providing a transition for the patient from a totally anesthetized state to care in the in-patient setting, Phase II,  or intensive care setting.¹ Assessment in the Postanesthesia Care Unit focuses on respiratory and cardiovascular systems and maintenance of a patient airway or continued ventilatory support.  The primary purpose of the PACU is critical assessment and stabilization of postanesthesia patients with an emphasis on prevention or treatment of complications.² These patients often need continued intensive care and require the nurse to possess critical thinking skills and complex nursing expertise. Postanesthesia Phase II focuses on preparing the patient and family for care in the home or extended care environment.¹ Because of the complexity of care and increased patient responsibilities in the immediate postoperative period, it is not surprising that TJC mandates that an RN supervise perioperative nursing care, and that a sufficient number of qualified staff are available to recover patients.³

< sectionheader >Assessing the Immediate Postanesthesia Patient

Before patients are transferred from the operating room to the PACU, receiving nurses need to know when they will arrive and what they will require, such as equipment for ventilatory support or monitoring. TJC’s standards require appropriate physiological monitoring and resuscitative equipment be available, as well as equipment to administer IV fluids, drugs, and blood and/or blood components, as necessary.³ Upon transfer, a thorough report from the anesthesia provider supplemented by the OR nurse should include relevant preoperative information regarding patient status, including emotional status; the surgical procedure performed; types of anesthesia and the drugs used; length of anesthesia or sedation; any reversal agents; pain management interventions; intraoperative estimated blood loss, surgical drain volume, and urine output; IV fluid and blood products infused; any anesthetic and surgical complications that occurred; vital signs, including pulse oximetry and temperature; and any co-existing medical disorders.1This report from the anesthesia provider to the PACU RN is a critical patient handoff, and accurate information about the patient is essential. TJC National Patient Safety Goal 2E requires that an opportunity to ask and respond to questions is provided.³

Expectations of TJC relative to monitoring of the postanesthesia patient include the following standards:

• The patient is assessed immediately after the procedure.
• Each patient’s physiological status, mental status, and pain level are monitored.
• Monitoring is at a level consistent with the potential effect of the procedure and/or sedation or anesthesia.³

The nurse accepting the patient needs to complete an initial assessment that includes the patient’s level of consciousness, vital signs, oxygen saturation, heart and breath sounds, surgical site and drainage devices, and IV access site so that any changes that occurred during transport can be identified immediately. Subsequently, a complete system assessment is performed and postoperative orders initiated. The report and assessment findings should be documented according to the institution’s policies and procedures.

Cardiopulmonary System: Maintenance of adequate gas exchange with adequate ventilation is vital. The patient should have unlabored, quiet respirations with adequate chest excursion; a respiratory rate of 16 breaths per minute to 20 breaths per minute is normal for an adult (higher in children), but may be slower, particularly in a patient who has received opioids. Patients should be encouraged to take deep breaths. The respiratory function should be monitored, including oxygen saturation, and if available and appropriate, end-tidal carbon dioxide levels.² Generally, an oxygen saturation level measured with a pulse oximeter should be higher than 92% to 94% or the same as preoperative status.

The cardiac output and perfusion should be assessed and monitored by checking arterial blood pressure for evidence of hypotension or hypertension — postoperative blood pressure should be plus or minus 20% compared to the preoperative measurement;⁴ heart rate and rhythm for signs of dysrhythmias; and skin color and temperature, and peripheral pulses for peripheral perfusion status. The fluid intake and output should be reviewed for indications of possible hypovolemia or hypervolemia, and also for total fluids infused, including blood products compared with urinary output, estimated blood loss, and volume in surgical drains. Peripheral edema or jugular venous distention should be noted. Numerous factors can alter cardiopulmonary function, including pain and residual anesthetic affects, and the underlying cause needs to be identified in order to effectively resolve the problem.

Central Nervous System (CNS): CNS assessment includes evaluation of consciousness, orientation, and behavior. Drugs used to produce general anesthesia cause unconsciousness as well as amnesia and analgesia. The incidence of emergence delirium ranges from 0% to 73.5%.⁵ Causes for emergence delirium include preexisting cognitive impairment, medication, pain, bladder distention, or cerebral hypoxia with the older patient at a greater risk.^5,6 Young children also frequently experience delirium.^6,7 The patient exhibits restlessness, confusion, and disorientation, and may be combative, uncooperative, or uninhibited during this time. Although the delirium does not last long, it is important to promote the patient’s safety as well as that of the health care professional by remaining calm, speaking softly, and reassuring and orienting the patient.^5-7 Drug therapy may be necessary to resolve the agitation, such as a benzodiazepine or physostigmine, which reverses agitation caused by atropine (an anticholinergic drug).⁷ However, before drug therapy is considered, other causes of delirium should be identified and corrected, such as hypoxia, hypercarbia, hypothermia, gastric dilatation, and urinary retention.^6,7

Temperature: Hypothermia, a core temperature below 36 C,⁷ is a common, but adverse, side effect of anesthesia. Every patient should be assessed for hypothermia and warming initiated for any hypothermic patient.8 Infants and the elderly are more susceptible to hypothermia because of immaturity and diminished sensitivity of temperature regulating mechanisms.⁷ The reduced metabolic rate caused by hypothermia can prolong the effects of anesthetics and delay recovery, while the associated shivering increases oxygen consumption⁷ four to five times, increasing the risk for angina and dysrhythmias in patients with cardiovascular disease. Postoperative shivering is controlled by using IV fluid warmers, skin surface warming devices such as forced warm air devices, and drugs such as meperidine (25 mg IV).^7-9

Anesthetic Techniques

Surgery within ORs can be performed under a variety of anesthetic techniques. Three concepts are integral to a comprehensive understanding of these methods and their effects on postoperative patients. Analgesia is defined as the lack of normal pain sensation.¹⁰ Amnesia, an essential element of general anesthesia and a desired element of regional and sedation techniques, is the absence of awareness of stimuli and events.¹¹ Anesthesia, a partial or complete loss of sensation with or without loss of consciousness,¹⁰ can be achieved by the use of regional or general techniques.

Many procedures are performed with IV sedation and local anesthesia that is injected at the surgical site, commonly referred to as monitored anesthesia care or local standby with sedation. Opioids and/or benzodiazepines and IV anesthetic agents, such as propofol (Diprivan), provide an anxiolytic and analgesic state while the surgeon provides local anesthesia.

Regional anesthesia includes spinal, epidural, and caudal anesthesia. This type of anesthesia interrupts the patient’s sensory, motor, and sympathetic nervous system impulse transmissions at the selected surgical site.¹² Used in conjunction with IV sedation, regional anesthesia can provide an effective alternative to general anesthesia in certain procedures on extremities or the lower abdomen. The drug used and the site of drug installation affect the intensity of blockade, as well as the adverse reactions and the level and duration of anesthesia.¹²

Postoperative care of patients with regional anesthesia includes assessment of the sensory and motor function in the area of the block. The return of motor function should be documented based on the patient’s ability to progressively move toes, feet, legs, and thighs. Return of sensory function is demonstrated by the ability to distinguish sensations of cold (alcohol swab) or touch (small gauge needle pricks). Patients with a “high” sensory/motor block (spinal/epidural) may complain of numbness and tingling of the hands and may exhibit signs of labored respirations.  Anesthesia-induced hypotension is due to vasodilatation caused by the sympathetic blockade that leads to decreased venous return and cardiac output. These patients need continuous assessment, including oxygenation and ventilation and vascular volume status, while supplemental oxygen is provided and venous return is increased using IV fluids and positioning. Patients who are having difficulty breathing or who have a reduction in oxygen saturation may require endotracheal intubation and ventilatory support, and those whose hypotension persists may need a sympathomimetic drug, such as ephedrine. Assessment for other causes of the hypotension, such as bleeding from the operative site, should also occur.¹²

General anesthesia produces unconsciousness, amnesia, analgesia, skeletal muscle relaxation, and control of sympathetic response to noxious stimuli.¹¹ A combination of drugs, administered as inhalants or intravenously, is used to achieve adequate surgical anesthesia. Nurses can anticipate potential problems if they know which agents have been used during the surgical procedure.

Opioids include morphine — the prototype to which all others are compared — fentanyl (Sublimaze), remifentanil (Ultiva), sufentanil (Sufenta), and alfentanil (Alfenta). Fentanyl is 75 times to 125 times more potent than morphine, remifentanil has an analgesic potency similar to fentanyl, and sufentanil is 5 times to 10 times more potent than fentanyl.¹³ Alfentanil is one-fifth to one-tenth as potent as fentanyl, which makes it a popular IV adjunct in outpatient settings because of its rapid onset and short duration of action. Opioids produce analgesia, euphoria, and sedation. Morphine reduces blood pressure due to vagal-induced bradycardia and histamine release, reactions not seen with other opioids such as fentanyl.¹³ Hydromorphone, similar to morphine, has seen a renewed popularity in the PACU. It has a rapid onset of action and virtual lack of active metabolites after breakdown in the liver.¹³ Due to the potential for histamine release, morphine is contraindicated for the asthmatic patient. Other adverse effects, including somnolence, urinary retention, nausea and vomiting, and respiratory depression (which may be reversed with naloxone), are common to all opioids.

Benzodiazepines produce amnesia. Diazepam (Valium) use is limited since the introduction of midazolam (Versed), which is shorter-acting. Adverse effects may include delayed awakening, somnolence, disorientation, amnesia, and postoperative respiratory depression, especially if used in conjunction with opioids. Flumazenil (Romazicon), a benzodiazepine antagonist, may be used to reverse significant adverse effects such as respiratory depression.

Barbiturates, including sodium thiopental (Pentothal) and methohexital (Brevital), have been a mainstay of IV anesthetic practice for over 50 years. These hypnotic producing drugs are used for induction or sedation and have a low incidence of postoperative nausea and vomiting. Large or repeated doses intraoperatively may prolong the drug’s effects postoperatively, causing delayed awakening, somnolence, hypotension, and respiratory depression. Barbiturates do not provide adequate analgesia and must be supplemented for pain control.¹⁴ Propofol (Diprivan), a sedative hypnotic, produces dose-dependent depression of the CNS. Approximately twice as potent as sodium pentothal, it may be used for sedation or induction and maintenance of general anesthesia. Other CNS depressants such as opioids increase propofol’s hypnotic effect. Adverse effects include hypotension, which is more pronounced if the patient is elderly or has poor left ventricular function — fluid resuscitation and vasopressor therapy may be required.¹⁴ Etomidate, another sedative hypnotic, is frequently used as an alternative to propofol and barbiturates for emergency surgery when volume resuscitation is ongoing and for patients with cardiac disease.¹⁴ It has less of an effect on blood pressure, heart rate, myocardial contractility, and cardiac output, compared to the other sedative hypnotic drugs.¹⁴ Involuntary muscle contractions or tremors are adverse effects; and nausea and vomiting are more common postoperatively than with thiopental or propofol.

Neuromuscular blocking agents (NMBA) are used principally to relax and paralyze skeletal muscles, facilitating endotracheal intubation and muscle retraction in the surgical field.¹⁵ They do not possess analgesic, amnesic, or anesthetic properties, and are classified according to how they act upon the neuromuscular junction, depolarizing or nondepolarizing. Succinylcholine (Anectine) is the only depolarizing NMBA currently available in the US, and there is no reversal agent for this drug.¹⁶ Nondepolarizing NMBAs include short acting mivacurium; intermediate acting rocuronium (Zemuron), vecuronium (Norcuron), cisatracurium (Nimbex), and atracurium (Tracrium); and long-acting pancuronium (Pavulon), d-tubocurarine (Tubarine), and doxacurium (Nuromax). Adverse effects may include cardiac dysrhythmias, postblockade myalgia, prolonged blockade, and persistent weakness.^16,17 There are also certain drugs, such as local anesthetics, antibiotics, antidysrhythmics, and diuretics that can potentiate the effects of NMBA, contributing to a prolonged recovery.^16,17 The most serious postoperative complication is inadequate reversal, which may result in short jerky attempts at respiration with little or no gas exchange. Patients exhibit uncoordinated “floppy fish” gasps for air. Nurses need to assess respiratory rate, oxygen saturation level, and tidal volume and report findings to the anesthesia provider. Reversal agents for nondepolarizing NMBA, neostigmine, edrophonium, or pyridostigmine, may be given if needed.^15,17 It’s recommended that an anticholinergic is given with the NMBA to prevent bradycardia, bronchoconstriction, and hypotension, which are adverse effects of these reversal agents; atropine is given with edrophonium or glycopyrrolate with neostigmine or pyridostigmine.^15,17 When the supine patient can lift his head off the bed and hold it for five seconds, neuromuscular blockade recovery is considered adequate.

Inhalation anesthetics, halothane, enflurane, isoflurane, desflurane, and sevoflurane are used for general anesthesia. In addition to depressing the central nervous system, these drugs depress baroreceptor sensitivity and myocardial and respiratory function. Nurses need to frequently assess blood pressure; cardiac rhythm; peripheral perfusion; and respiratory rate, rhythm, and depth.¹¹

< sectionheader >General Anesthesia Postoperative Complications

Respiratory depression (reduced tidal volume, respiratory rate, and O₂ saturation) may result from residual drug effects. Inadequate reversal of muscle relaxants reduces tidal volume; if unresolved by additional reversal agents, reintubation may be necessary. Residual opioids primarily diminish respiratory rate, and patients may require naloxone (Narcan) titrated to reverse narcotic depression. On occasion, reduced tidal volume and O₂ saturation result from pain and splinting, and may improve with opioid analgesia. Because patients who have had general anesthesia have had some interference with their respiratory processes, most experts suggest these patients should receive supplemental oxygen during the recovery period.¹⁸

Upper airway obstruction can also result from relaxation of the pharyngeal musculature due to residual drug effects. The patient should be observed for signs of obstruction, such as snoring, nasal flaring, and sternal retractions.⁴ Raising the head of the bed if not contraindicated, or performing a simple jaw lift or mandible thrust, is often sufficient to bring the tongue forward and relieve the upper airway obstruction. If this is ineffective, a nasal airway can be inserted. If a nasal airway is contraindicated by a history of epistaxis, cranial surgery, facial fractures, or a low platelet count, an oral airway may be inserted if the patient is unconscious;⁴ stimulation of the patient’s gag reflex may cause vomiting, increasing the risk for aspiration. If upper airway obstruction is not relieved immediately, the anesthesia provider should be notified to assess for reintubation.

Mechanical obstacles, such as teeth, vomitus, or hematomas may also cause obstruction. Patients who have had head and neck surgery need continuous assessment for airway patency. Hemorrhage and/or clot formation at the surgical site may require further surgical exploration. An emergency tracheostomy setup needs to be at the bedside for these patients.

Laryngospasm, which may result in complete closure of the vocal cords and inability of the patient to ventilate, requires immediate assistance from anesthesia personnel. Those at risk for laryngospasm include patients with chronic pulmonary disease, those who smoke, those with a history of asthma, or those who had a difficult intubation. Patients will often display “rocky” abdominal respirations with no air exchange. Initial treatment is positive pressure ventilation using a bag valve mask device with 100% O₂. The anesthesia provider will give a nonparalyzing dose of succinylcholine (about one-tenth of the full intubating dose) if this maneuver is unsuccessful. Reintubation may be a last resort.¹⁹

Hypotension is commonly caused by hypovolemia from hemorrhage, insensible (third space) losses, or inadequate fluid replacement. But hypotension can also be caused by decreased systemic vascular resistance and myocardial contractility, which are residual effects of anesthetic agents.⁶ Arterial hypoxemia, cardiac dysrhythmias, pulmonary embolism, pneumothorax, and cardiac tamponade can also lead to hypotension.⁶

Treating hypotension depends upon its etiology; however, oxygen therapy is usually a standard treatment regardless of cause. Assessment starts with an evaluation of fluid status, including a thorough review of estimated intraoperative blood loss and fluid replacement, urine output, and postoperative bleeding at the wound site and from surgical drains. If blood loss is suspected, hemoglobin and hematocrit levels should be checked. Evidence of bleeding and a low hematocrit level are signs of inadequate surgical hemostasis, and the surgeon should be notified. Based on a patient’s cardiovascular status, fluid challenges of 200 cc to 500 cc may restore blood pressure to baseline values if hypovolemia is present.¹⁹ Other etiologies require further assessment and specific treatments.

Hypertension in the immediate postoperative period is often due to the sensation of pain as the patient emerges from anesthesia.6 However, it may result from hypoxemia, hypercarbia, a full bladder, hypothermia with arterial and venous constriction, fluid overload, and the administration of exogenous sympathomimetic agents, such as ephedrine or neosynephrine.¹⁹ As with hypotension, the etiology of hypertension determines treatment. First, the nurse should assess such factors as airway and ventilation, unrelieved pain, or the presence of a full bladder. Correction and treatment of one or more of these factors may return the patient’s blood pressure to baseline value. Patients may need to be reassured, have their fears allayed, have analgesics administered for pain, their bladders emptied, and be encouraged to deeply breathe and cough. Patients with preexisting hypertension, who often exhibit wide ranges of blood pressure postoperatively, need to be carefully returned to baseline values with antihypertensive medications, calcium channel blockers, or vasodilators.

Aspiration may occur in patients recovering from general anesthesia and IV sedation when airway reflexes are impaired. Patients most commonly aspirate gastric contents, which can result in severe pneumonitis and bronchospasm with resultant hypoxemia. Some signs include wheezing, sustained coughing, and laryngospasm. Pulmonary infiltrates may appear on the chest X-ray immediately or within 24 hours of the event.^19,20  Postoperative aspiration is life-threatening, and patients demonstrating an inability to maintain a patent airway or the absence of pharyngeal or laryngeal reflexes require immediate intervention by anesthesia personnel. Postoperative endotracheal intubation may be required to protect the airway from gastric contents or foreign materials.

Skeletal muscle pain, especially in the neck, abdomen, and back, may occur from the use of the depolarizing muscle relaxant, succinylcholine. The discomfort is thought to be due to muscle damage caused by unsynchronized contractions of the skeletal muscles (fasciculations) associated with generalized depolarization.¹⁵ Patients who exhibit skeletal muscle myalgia postoperatively should be reassured that the duration of this pain is generally short, dissipating within 24 hours to 48 hours. Treatment of myalgia includes analgesics, such as acetaminophen (Tylenol).

Nausea and vomiting is one of the most common postoperative problems affecting 20% to 30% of patients.6 Primary risk factors fall into three categories: patient-specific, anesthetic-related, and surgery related. A patient with risk factors, including female gender, non-smoking history, use of opioids, and history of post operative nausea and vomiting (PONV), or motion sickness, has an 80% chance of having PONV, with each risk factor increasing the risk of PONV. Pharmacologic agents that block serotonin (5-HT3) receptors are ondansetron, dolasetron, or granisetron, agents that work peripherally and centrally in the chemoreceptor trigger zone of the brain. Dopamine receptor agents, such as prochlorperazine (Compazine) and droperidol, block the dopamine (D2) receptor sites. Droperidol was a common treatment until the FDA black box warning regarding possible dysrhythmias. Promethazine or dephenhydramine can be given to block the histamine receptor sites. Glycopyrrolate or scopolamine patches can be used for the muscarinic receptors. Dexamethasone (Decadron) has been used effectively, especially in combination with a serotonin or dopamine blocking agent. Metoclopramide blocks D2 receptor sites and enhances gastric emptying. The newest drug is apretitant, which targets the neurokinin 1 (NK-1) receptors and is available orally for prophylaxis of PONV.²¹

Other measures to reduce nausea and vomiting are the administration of oxygen, analgesics, decreased stimulation and movement of the patient, adequate hydration, aromatherapy, and P6 acupoint stimulation with acupuncture or acupressure techniques can be effective.^6,22 The nurse should work together as a team with the anesthesia provider to follow multidisciplinary guidelines instituted to guide the care of the postanesthesia patients.²³

Discharge Criteria from the Post Anesthesia Care Unit

The Joint Commission’s standards require patients to be discharged from the PACU by a licensed independent practitioner or according to rigorously applied criteria approved by the medical staff.³ An example of such criteria follows:

• A patent airway.
• Adequate tidal volume, respiratory rate, and oxygen saturation with or without supplemental oxygenation.
• Stable vital signs for an established period of time based on the procedure and anesthesia technique.
• Alertness when stimulated (able to be aroused and capable to summon help from the nursing staff).
• A tolerable level of pain, which is variable for each individual patient. Patients should not be discharged immediately after an initial dose of opioid.
• Adequate return of motor and sensory function (patients who have received regional anesthesia with supplemental sedation).

Instead, a numeric scoring system previously approved by the department of anesthesia may be used to determine patient readiness for discharge from the PACU.⁴ The most common scoring system for the Phase I PACU patient in use presently is the Aldrete scoring system. Activity, respiration, circulation, consciousness, and oxygen saturation level are scored from 1 to 2, with a total score of 8 to 10 as acceptable for PACU discharge.

The postanesthesia caregiver should give a full report of the intraoperative course of events and postanesthesia phase to the nurse assuming care of the patient after discharge from the postanesthesia care unit, again allowing for an opportunity to ask and respond to questions.²

Patients may receive anesthesia through a variety of techniques in the surgical suite. Regardless of the technique, they all require careful postoperative monitoring and assessment. With the advent of new technology and pharmacological adjuncts, morbidity associated with the administration of anesthesia has dropped dramatically. Postoperative monitoring and recovery of the patient is still a time for careful assessment and skilled intervention. Effective collaboration between anesthesia and nursing services promotes quality patient care and positive surgical outcomes.