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    Formerly anesthetized patients should not leave the operating room unless they have a patent airway, have adequate ventilation and oxygenation, and are hemodynamically stable; qualified anesthesia personnel must also be available to attend the transfer.
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    Before the recovering patient is fully responsive, pain is often manifested as postoperative restlessness. Serious systemic disturbances (eg, hypoxemia, respiratory or metabolic acidosis, or hypotension), bladder distention, or a surgical complication (eg, occult intraabdominal hemorrhage) must also be considered in the differential diagnosis of postoperative agitation.
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    Intense shivering causes precipitous rises in oxygen consumption, CO2 production, and cardiac output. These physiological effects are often poorly tolerated by patients with preexisting cardiac or pulmonary impairment.
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    Respiratory problems are the most frequently encountered serious complications in the postanesthesia care unit (PACU). The overwhelming majority are related to airway obstruction, hypoventilation, and/or hypoxemia.
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    Hypoventilation in the PACU is most commonly due to the residual depressant effects of anesthetic agents on respiratory drive.
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    Obtundation, circulatory depression, or severe acidosis (arterial blood pH < 7.15) is an indication for immediate and aggressive respiratory and hemodynamic intervention, including airway and inotropic support as needed.
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    Following naloxone administration, patients should be observed closely for recurrence of opioid-induced respiratory depression (“renarcotization”), as naloxone has a shorter duration than do most opioids.
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    Increased intrapulmonary shunting from a decreased functional residual capacity relative to closing capacity is the most common cause of hypoxemia following general anesthesia.
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    The possibility of a postoperative pneumothorax should always be considered following central line placement, intercostal blocks, abdominal or chest trauma (including rib fractures), neck dissections, tracheostomy, nephrectomies, or other retroperitoneal or intraabdominal procedures (including laparoscopy), especially if the diaphragm may have been penetrated or disrupted.
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    Hypovolemia is by far the most common cause of hypotension in the PACU.
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    Noxious stimulation from incisional pain, endotracheal intubation, or bladder distention is usually responsible for postoperative hypertension.

Historically, emphasis on specialized nursing care during the immediate postoperative period was prompted by the realization that many early postoperative deaths occurred immediately after anesthesia and surgery and that many of these deaths were preventable. A nursing shortage in the United States following World War II, as well as the experience of providing surgical care to large numbers of battle casualties during the war, contributed to the postwar trend of centralization of immediate postoperative care in the form of recovery rooms, where one or more nurses could pay close attention to several acute postoperative patients at one time. Over the past two decades, the accelerating 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, often in the setting of a shortage of surgical intensive care beds. The success of PACUs in decreasing postoperative morbidity and mortality has been a major influence on the evolution of modern surgical intensive care units.

Another recent transformation in postanesthesia care is related to the shift from inpatient to ...

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