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  • image Patients emerging from anesthesia should not leave the operating room until they have a patent airway, have adequate ventilation and oxygenation, and are hemodynamically stable; qualified anesthesia personnel must attend the transfer to the postanesthesia care unit (PACU).

  • image Before the recovering patient is fully responsive, pain is often manifested as postoperative restlessness or agitation. Significant systemic disturbances (eg, hypoxemia, respiratory or metabolic acidosis, hypotension), bladder distention, or a surgical complication (eg, occult intraabdominal hemorrhage) must also be considered in the differential diagnosis of postoperative restlessness or agitation.

  • image Postoperative nausea and vomiting (PONV; see Chapter 17) is the most common significant complication following general anesthesia, occurring in approximately 30% or more of all patients.

  • image Intense shivering causes precipitous rises in oxygen consumption, CO2 production, and cardiac output. These physiological effects may be poorly tolerated by patients with cardiac or pulmonary impairment.

  • image Respiratory problems are the most frequently encountered serious complications in the PACU. The overwhelming majority are related to airway obstruction, hypoventilation, hypoxemia, or a combination of these problems.

  • image Hypoventilation in the PACU is most commonly due to the residual depressant effects of anesthetic agents on respiratory drive, often made worse by preexisting obstructive sleep apnea.

  • image Hypoventilation with obtundation, circulatory depression, and severe acidosis (arterial blood pH < 7.15) is an indication for immediate and decisive ventilatory and hemodynamic intervention, including airway and inotropic support as needed.

  • image Following naloxone administration, patients should be observed closely for recurrence of opioid-induced respiratory depression (“renarcotization”), as naloxone has a shorter duration of action than many opioids.

  • image Increased intrapulmonary shunting from a decreased functional residual capacity relative to closing capacity is the most common cause of hypoxemia following general anesthesia.

  • image The possibility of a postoperative pneumothorax should always be considered following central line placement, supraclavicular or intercostal blocks, abdominal or chest trauma (including rib fractures), neck dissection, thyroidectomy (especially if thyroid dissection extends into the thorax), tracheostomy, nephrectomy, or other retroperitoneal or intraabdominal procedures (including laparoscopy), especially if the diaphragm may have been penetrated or disrupted.

  • image Hypovolemia is the most common cause of hypotension in the PACU and can result from inadequate fluid replacement, wound draining, or hemorrhage.

  • image Noxious stimulation from incisional pain, endotracheal intubation, bladder distention, or preoperative discontinuation of antihypertensive medication is usually responsible for postoperative hypertension.

Historically, emphasis on specialized nursing care during the immediate postoperative period was prompted by the realization that many preventable early postoperative deaths occurred immediately after anesthesia and surgery. The World War II experience of providing surgical care to large numbers of battle casualties contributed to the postwar trend of centralization of immediate postoperative care in recovery rooms, where skilled nurses could pay close attention to several acute postoperative patients simultaneously. Recently, the practice of caring for selected postoperative patients overnight in a postanesthesia care unit (PACU), or the equivalent, has been a response to increasingly complex surgical procedures performed on higher-acuity patients, when there is a shortage of surgical ...

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