General Goals:
- Understand how to use the various components
of the anesthesia record and the report from the anesthetizing
anesthesiologist to optimally care for the patient recovering from anesthesia
and surgery.
- Observe, recognize, and learn
to treat the most commonly occurring problems to arise in the Postanesthesia
Care Unit (PACU).
SPECIFIC COMPETENCIES:
(General
Competencies also apply)
Patient Care Skills
- Be able to assess adequacy of the patient's
postoperative airway
- Develop a differential diagnosis for
airway compromise and a plan of action
- Recognize and appropriately manage airway
compromise with
- Supplemental oxygen
- Adjunctive airway devices
- Assisted ventilation by bag and mask
- Endotracheal intubation
- Pharmacologic measures including assessment and
reversal of neuromuscular blockade and opiates
- Recognize, develop differential diagnoses,
and treat common perioperative arrhythmias
and know when to consult specialists outside
anesthesiology
- Evaluate and treat postoperative hypertension
- Develop a differential diagnosis of
postoperative hypertension
- Appropriately use beta-blockade and / or
vasodilators to treat hypertension as needed
- Recognize and develop a differential
diagnosis of postoperative hypotension
- Appropriately treat hypotension with IV
fluids, blood / blood products, or pharmacologic measures
- Develop strategies for pain prevention on
the patients arrival in the PACU. Be able to provide appropriate safe
pain relief in the PACU using various pharmacologic measures including
opiates and non-opiate medications.
- Develop a differential diagnosis for
postoperative nausea and vomiting.
- Appropriate treat postoperative nausea
and vomiting using IV fluids, pharmacologic measures
- Develop a differential diagnosis for
postoperative decreased urine output and appropriately treat decreased urine
output with fluids or other needed measures
- Recognize and treat emergence related
delirium. Develop a differential diagnosis of delirium
- Recognize and appropriately evaluated delayed emergence from anesthesia. Using the anesthetic record, record of the surgical procedure, and the
patient's medical history, develop an appropriate differential diagnosis and
evaluation / management plan for the delayed emergence.
- Appropriately manage postoperative
shivering.
- Use information about the patient
that is received and observed on admission to the PACU and during care
there for the following purposes:
- To
create a care plan
- To
score the patient's condition according to the Aldrete system
- To
assess the patient's recovery and condition for a safe discharge or transfer
- Appropriately apply criteria for safe
discharge from or bypass of the PACU to the following:
1. Home
2. inpatient
ward
3. Intensive
care unit
MEDICAL KNOWLEDGE
- Postoperative nausea and vomiting
- Theoretical pathophysiology
- Various treatment modalities - both
pharmacologic and non-pharmacologic
- Postoperative pain control
- Intravenous agents
- various opiates: advantages,
disadvantages, side-effects of each
- non-opiate agents including non-steroidal
medications
- adjunctive agents dealing primarily with
anxiety components of pain
- Regional anesthesia techniques (for specific
knowledge goals - see regional anesthesia rotation). Know how
to assess proper function of each of these pain control modalities.
- Epidural
- Continuous plexus catheters
- Nerve sheath catheters
- Airway and ventilatory function
- Know criteria and methods for assessment of
patient readiness for extubation post anesthesia and surgery
- Proper interpretation and use of blood gases
- Various testing methods of respiratory muscle
function
- Arrhythmias
- Know recognition criteria for common
perioperative arrhythmias
- Causes of perioperative arrhythmias
- Appropriate treatment for common perioperative
arrhythmias
- Cardiovascular system
- Sufficient knowledge of cardiovascular
physiology and pharmacology to be able to develop differential diagnoses
and treatment plans for hypertension and hypotension
- Knowledge of common surgical procedures: Possess sufficient knowledge of common surgical procedures to be able to
anticipate, recognize and appropriately treat postoperative problems and
complications associated with each operation.
- Criteria for Discharge from the PACU
- Home
- Regular floor bed
- Intermediate care unit
INTERPERSONAL AND COMMUNICATION SKILLS,
PROFESSIONALISM
- See general
competencies section
- Ability to communicate postoperative information
to the surgical team accurately and efficiently, particularly when
postoperative problems may be related to surgical complications.
PRACTICE-BASED LEARNING AND
IMPROVEMENT
- See general
competencies section
- Learn to evaluate and manage patients so that
time spent in PACU is appropriate and not prolonged by unmanaged pain,
nausea and vomiting or concomitant medical problems.
- Practice self education by using
down-time between patient arrivals from the operating room
for independent study (see Teaching Resources for details on reading
material)
- Participate in the education of PACU nursing staff by giving one 15- to 20-minute presentation on a
topic relevant to postanesthesia care. (PACU medical director available
to assist)
SYSTEMS-BASED PRACTICE
- See general
competencies section
- Learn to work with nursing and administrative
personnel to get patients as quickly as possible to their longer term
recovery sites (home, floor, ICU) thus allowing for efficient continuing
care in the operating room and preventing PACU related delays in surgery.
- Learn study design, data collection, and
when appropriate, manuscript writing by participating in departmental
studies in the PACU when they are underway
Evaluation to Determine Goal Achievement:
- Medical director meets with you at the
beginning of the rotation to acquaint you with expectations and resources
available. At the end of the rotation, you meet with the rotation director
to discuss the rotation.
- You are evaluated weekly on-line
by attendings who worked with you. In this case, the PACU medical director will complete your primary evaluations. In addition, the five attendings with
the greatest volume of patients going through the PACU will also be asked to
evaluate your performance. The evaluation data are reviewed quarterly by the Clinical
Competence Committee. Your advisor informs you of any problems identified,
and serious problems will be discussed with you immediately after they
occur.
- You will complete a Departmental Rotation
Evaluation Form.
- The Program Director will evaluate the
results of the In-Training Examination for the American Board of
Anesthesiologists (ABA) in general and for areas of departmental weakness.
Consistent weaknesses may result in adjustment of the above goals.
Teaching Resources to Accomplish the
Objectives:
- Patients: > 16,000 per year
of all ages and with all types of pathology undergo care at Shands Teaching
Hospital, 80% of whom are admitted to the PACU and 20% of whom are admitted
directly to an intensive care unit.
- Reading material
- Text
books: available in PACU (titles included with attached bibliography)
- Reading
file of reprints maintained in PACU (Bibliography attached)
- Facilities: An office is available
for the resident in PACU with desktop computer for access to patient data,
departmental database, and MEDLINE.
- Faculty:
- General: All teaching faculty
participate; all are board eligible or certified anesthesiologists
with a commitment to resident education. Many have dual board
certification and sub-specialty training with certification where
available. Other professionals such as those in the Computer Division
assist with such resources as the desktop computer.
- Dietrich Gravenstein, MD, Medical
Director of the Postanesthesia Care Unit
- References:
- Aldrete Ja, Kroulik D: A Postanesthestic
Recovery Score, Anesth Analg 49:924-932.
- Aldrete JA, Wright AJ: Postanesthesia
Scores, Anesthesiology News, November 1992.
- Ali J, Weisel RD, Etal: Consequences
of Postoperative Alterations in Respiratory Mechanics, Am J of Surgery
128:376-382, 1974.
- Bay J, Nunn JF, Etal: Factors Influencing
Arterial PO2 During Recovery From Anaesthesia, Brit J Anaesth 40:398-406,
1968.
- Berger JJ: Transurethral Resection
of the Prostrate, Current Reviews in Clinical Anesthesia 9:Lesson 4, 1988.
- Catley DM, Thornton C, Et Al: Pronounced,
Episodic Oxygen Desaturation in the Postoperative Period: Its Association
with Ventilatory Pattern and Analgesic Regimen, Anesthesiology 63:20-28,
1985.
- Cohen MM, Duncan PG, Etal: A Survey
of 112,000 Anesthetics at One Teaching Hospital (1975-83), Can Anaesth
Soc J 33:22-31, 1986.
- Coriat P, Mundler O: Response of
Left Ventricular Ejection Fraction to Recovery From General Anesthesia:
Measurement By Gated Radionuclide Angiography, Anesth Analg 65:593-600,
1986.
- Craig DB: Postoperative Recovery
of Pulmonary Function, Review Article, Anesth Analg 60:46-52, 1981.
- Dibenedetto RJ, Graves SA, Gravenstein
N, Konicek C: Pulse Oximetry Monitoring Can Change Routine Oxygen Supplementation
Practices in the Postanesthesia Care Unit, Anesth Analg 73: 365-368, 1994.
- Eckenhoff, J.E., Et Al: The Incidence
and Etiology of Postanesthesia Excitement, Anesthesiology, 22;667-673,
1961.
- Fishman AP: Hypoxia on the Pulmonary
Circulation, Circ Research 38:221-231, 1976.
- Frost EAM: Differential Diagnosis
of Postoperative Coma, Int Anes Clin 21:1:13-30, 1983.
- Gal TJ, Cooperman LH: Hypertension
in the Immediate Postoperative Period, Brit J Anaest, 47:70-74, 1975.
- Hanning CD: Monitoring Respiration
in the Postoperative Period (Editorial), Brit J Anaesth 54:577-579, 1982.
- Hines R, Barash PG, Etal: Complications
Occuring in the PostAnesthesia Care Unit: A Survey, Anesth Analg 74:503-9,
1992.
- Korttila J: How to Assess Recovery
From Anesthesia, ASA Refresher Courses (224), 1987.
- Lynn AM, Slattery JT: Morphine
Pharmacokinetics in Early Infancy, Anesthesiology 66:136-139, 1987.
- Mangano DT, Siliciano D, Et Al:
Postoperative Myocardial Ischemia, Anesthesiology 76:342-353, 1992.
- Scott, LE, Clum, GA, Peoples, JB:
Postoperative Predictors of Postoperative Pain. Pain 15; 283-293, 1983.
- Stoelting RK, Eger EI, The Effects
of Ventilation and Anesthetic Solubility on Recovery From Anesthesia: An
in Vivo and Analog Analysis Before and After Equilibrium, Anesthesiology
30:290-296, 1969.
- Watcha MF, White PF: Postoperative
Nausea and Vomiting, Anesthesiology 77:162-184, 1992.
- Wetchler BV: Postoperative Management,
Discharge, and Follow-Up, Anesthesiology Clinics of North America 5:113-136,
1987.
- Yaster M, Deshpande, JK: Management
of Pediatric Pain with Opioid Analgesics, Journal of Pediatrics, 113:421-429,
1988.
- Youngberg JA, Neely CF: Perioperative
Anesthetic Considerations for the Cartoid Artery Surgery Patient, ADV Anesthesia
5:291-328, 1988.
- BOOKS:
- Harriet Lane Handbook
- Venders,JS, Spiess, BD (EDS): Post
Anesthesia Care, WB Saunders Co, 1992.
- White, PF (EDS): Outpatient
Anesthesia, Churchill Livingstone, Inc, 1990.
Dr. Dietrich Gravenstein is the responsible faculty
member for this rotation.
RETURN
TO INDEX FOR GOALS AND OBJECTIVES
Revised 7/2004, reviewed 6/2005
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