Chapter 71

1. Complications in the postanesthesia care unit (PACU) are common. Despite pharmacologic and medical advances over the last 10 years, the incidence of postoperative complications appears largely unchanged. Even minor postoperative complications are important to patients, and greater efforts at preventing and treating such complications should lead to improved postoperative recovery and patient satisfaction.

2. Knowledge of the expected postoperative course for a given operation is essential to identifying and managing problems when they occur. Awareness of the temporal patterns of complications is important to anticipating periods of increased perioperative risk.

3. Airway obstruction is common in the postoperative period. Upper airway obstruction arises in the pharynx (posterior tongue displacement, soft tissue collapse), larynx (laryngeal edema, laryngospasm, vocal cord paralysis), or trachea due to extrinsic compression. Anesthetics, and even minimal residual neuromuscular blockade, may lead to upper airway obstruction.

4. Hypoxemia is common in postoperative patients not receiving supplemental oxygen (O2). Following general anesthesia or sedation, all patients should receive supplemental O2 during their transport from the operating room and during their initial PACU stay. Continuous monitoring of O2 saturation with pulse oximetry is essential for early detection of hypoxemia.

5. Several conditions may necessitate continued intubation after surgery. They include delayed emergence from general anesthesia, inadequate reversal of neuromuscular blockade, potential for airway obstruction, inadequate gas exchange, and hemodynamic instability.

6. Hypotension is a common postoperative complication that results from hypovolemia (most common), decreased vascular tone, and/or reduced cardiac output. Causes of hypovolemia in the PACU include inadequate fluid replacement, ongoing hemorrhage, and fluid sequestration ("third spacing"). Clinical evaluation of a patient's intravascular volume status requires consideration of preoperative status, type and duration of surgery, estimated blood loss, fluid replacement, and evidence of hemostasis.

7. Cardiac dysrhythmias are common during the perioperative period, and most dysrhythmias are benign. The precipitating factor is usually a transient imbalance such as hypoxia, ischemia, increased catecholamines, altered acid–base status, or electrolyte abnormalities. The management strategy for a new dysrhythmia is focused on stabilizing hemodynamics and treating the underlying problem.

8. Hypertension is a very common problem in the postoperative period. Sympathetic nervous system activation resulting from noxious stimuli, such as pain, anxiety, bladder distension, fluid overload, hypoxemia, hypercarbia, and hypothermia, are common precipitants. The decision to treat hypertension should take into consideration the patient's baseline blood pressure, coexisting diseases, and perceived risk of complications.

9. Urinary retention and oliguria are common problems in the PACU. Oliguria is most commonly caused by hypovolemia (prerenal) in the immediate postoperative period, but postrenal and intrinsic renal causes should also be considered.

10. Patients who develop bleeding postoperatively require rapid evaluation to differentiate poor surgical hemostasis (which may require immediate reoperation) or from a diffuse coagulopathy. It is important to appreciate that surgical and nonsurgical bleeding often coexist. If there is evidence of significant bleeding, diagnosis and treatment usually occur simultaneously. Adequate intravenous (IV) access should be established, availability of appropriate blood products ensured, and a diagnostic evaluation performed.

11. Hypothermia remains a common PACU problem. Even mild hypothermia (core temperature ...

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