After the PACU nurse assesses the ABCs (airway, breathing, circulation), the perioperative nurse and anesthesia provider give a comprehensive hand-off report. A patient hand-off is defined by the Joint Commission Center for Transforming Healthcare (2010) as a transfer and acceptance of patient care responsibility achieved through effective communication. It is a real-time process of passing patient-specific information from one caregiver to another or from one team of caregivers to another for the purpose of ensuring continuity and safety. Standardization of how information is communicated ensures that the information will be accurate and complete. The perioperative nurse collaborates by adding and verifying important patient information. Box 10-1 includes suggestions on what each surgical team member reports.

The patient’s American Society of Anesthesiologists (ASA) physical classification status (see Chapter 5) also is provided during the hand-off report. Useful information that the perioperative nurse also provides includes airway status and presence of tubes, drains, catheters, and intravascular lines. Any postoperative orders to be initiated in the PACU are discussed at this time.

The anesthesia provider should not leave the patient until the PACU nurse accepts responsibility for the patient’s care. Standard III-3 of the ASA’s Standards for Postanesthesia Care (ASA, 2009) states that “the member of the anesthesia care team shall remain in the PACU until the PACU nurse accepts responsibility for the nursing care of the patient.”

After immediate assessment of the ABCs and completion of the hand-off report, the PACU nurse begins a more thorough postanesthesia assessment. The assessment is performed quickly and is specific, in part, to the type of operative procedure. Recommended elements of an initial assessment in the PACU are presented in Box 10-2.

Some PACUs use a head-to-toe assessment to organize the data obtained (Figure 10-1). Other PACUs take a major body systems approach (Figure 10-2). In any case, the PACU nurse assesses admitting vital signs and the ABCs, beginning with the respiratory system. Respiratory assessment comprises rate, rhythm, auscultation of breath sounds for ventilatory adequacy, oxygen saturation level, and end-tidal CO₂ level if applicable. Any artificial airway and type of oxygen delivery system are noted.

The first priority in the care of the postanesthesia patient is to establish a patent airway. A common cause of airway obstruction is the tongue, which is relaxed because of anesthetic agents and muscle relaxants used during surgery (Nicholau, 2009) (Figure 10-3). The patient may present with snoring, little or no air movement on auscultation of the lungs, retraction of intercostal muscles, asynchronous movements of the chest and abdomen, and a decreased oxygen saturation level. The nursing action taken may be simple, such as stimulating the patient to take deep breaths, positioning the patient on the side, or providing supplemental oxygen. If the patient is still unresponsive, the nurse may need to open the airway with a chin tilt or jaw thrust. A chin tilt is accomplished by lifting the chin with one hand while tilting the forehead back with the other. A jaw thrust is accomplished by displacing the temporomandibular joint forward bilaterally. The patient also can be repositioned on the right side. This position is called the recovery position. Placing the patient in this position allows the tongue to move forward and the airway to remain open.

If these actions do not open the airway, an artificial airway may need to be inserted. An oral or nasal airway may be used. An oral airway is used with an unresponsive patient (Figure 10-4). A nasal airway, better tolerated by an awake patient, is indicated for patients who are arousable.

A serious PACU complication is laryngospasm, usually the result of an irritable airway. Laryngeal obstruction may occlude the airway as a result of partial or complete spasm of the intrinsic or extrinsic muscles of the larynx. The muscles of the larynx contract and the vocal chords either partially or completely obstruct the airway; the patient can become hypoxemic quickly (Drain, 2013). With laryngospasm, remove the irritating stimulus, suction secretions that may be triggering a glottic response, hyperextend the patient’s neck, oxygenate the patient, and prepare to administer an aerosol with racemic (optically inactive) epinephrine. An awake patient experiencing a laryngospasm is terrified and needs reassurance and a calm demeanor from nurses and physicians. In many cases, positive-pressure ventilation is delivered by mask and bag. If symptoms last longer than 1 minute and are unrelieved by positive pressure, administration of a muscle relaxant, such as succinylcholine, by the anesthesia provider is required to relax the muscles of the larynx (Drain, 2013). Reintubation is undesirable and used only as a last resort.

Bronchospasm is a lower airway obstruction caused by spasms of the bronchial tubes. These spasms can cause complete airway closure because of lack of cartilaginous support in the bronchioles. The patient presents with wheezing, dyspnea, use of accessory muscles, and tachypnea (Odom-Forren, 2014). Bronchospasm can result from aspiration, pharyngeal suctioning, or histamine release secondary to allergic response or related to medication use. Inhaled bronchodilators are the first choice of therapy for these patients, followed by IV aminophylline. Both IV and inhaled lidocaine can ease bronchospasm induced by histamine (Benca, 2007). If bronchospasm becomes life threatening, epinephrine may be administered. Steroids, such as methylprednisolone, also may be administered if the underlying cause is inflammatory disease (e.g., asthma).

When obstruction occurs, partial pressure of arterial carbon dioxide (PaCO₂) increases significantly and quickly. With obstruction, the PACU nurse makes a quick assessment, rapidly intervenes with airway assistance, and calls for help from the anesthesia provider.

Hypotension has been defined as a blood pressure reading that is 20% less than baseline or preoperative blood pressure measurement; it indicates either relative or absolute hypovolemia (O’Brien, 2013b). Clinical signs of hypotension include a rapid, thready pulse; disorientation; restlessness; oliguria; and cold, pale skin. Because hypovolemia is the most common cause of postoperative hypotension, the initial intervention is to administer IV fluids (physiologic saline or lactated Ringer’s solution) at a maximum rate while making a specific diagnosis.

Cardiac output and vascular resistance determine blood pressure. Hypotension may be caused by cardiac dysfunction (such as myocardial infarction, tamponade, embolism, ischemia, dysrhythmias, congestive heart failure, valvular dysfunction) or by medications (including anesthetic agents). In such cases, the heart no longer pumps effectively. Hemodynamic monitoring, supplemental oxygen, and cardiac stimulants are used as needed.

Decreased vascular resistance, which causes relative hypovolemia (interference with venous return to the heart), can be related to medications, general and regional anesthesia, or anaphylaxis (Odom-Forren, 2014). Vasodilation can be treated with fluids, vasopressors, or by elevating the patient’s legs. Anaphylactic reactions are treated with epinephrine, antihistamines, and additional fluids.

The normal ranges for systolic and diastolic blood pressures are generally accepted as 100 to 140 mm Hg and 60 to 95 mm Hg, respectively, although these ranges vary. Hypertension has been defined as a 20% to 30% increase above baseline blood pressure measurement or persistent elevation of systolic blood pressure greater than 140 or diastolic pressure greater than 90 (O’Brien, 2013b; Odom-Forren, 2014). Hypertension is among the most common postoperative complications and often occurs early in the recovery phase. Blood pressure must be verified and rapidity of its change noted. Clinical signs and symptoms are the most important indicators of the severity of the hypertension. Headache, mental status changes, and substernal pain are all indicators of end-organ damage. Hypertension may be caused by volume overload or pulmonary edema, which causes an increase in the cardiac output. In this case the patient is given diuretics, placed on fluid restriction, and hemodynamically monitored. The patient with a history of cardiac disease is more at risk for adverse results.

Asymptomatic hypertension commonly occurs in the PACU and is usually considered harmless. The solution usually is determined by the cause. Patients with a history of essential hypertension are more likely to experience systemic hypertension in the PACU (Nicholau, 2009). Pain is one of the most common causes of hypertension. Other causes of hypertension are anxiety, reflex vasoconstriction from hypothermia, hypoxemia, hypercapnia, and viscus distention, all of which cause increased vascular resistance. Patients in pain are medicated, and patients with hypothermia are warmed. Patients are oxygenated and ventilated if necessary to improve hypoxemia or hypercapnia. Patients are encouraged to void or are catheterized to empty a full bladder.

Antihypertensive drugs are used as necessary to control blood pressure. Beta-blockers and α₂-agonists may be used postoperatively when needed. Other agents are available and may include the patient’s usual prescription for hypertension (Odom-Forren, 2014). Patients who were on beta-blockers prior to surgery should be given a beta-blocker the day of surgery. Surgery patients receiving a beta-blocker during the perioperative period is one of the Surgical Care Improvement Project (SCIP) measures evaluated during the perioperative period (TJC, 2013). Patients should resume taking prescribed preoperative antihypertensives as soon as possible after surgery. Ambulatory surgery patients and inpatients usually are directed to take their prescribed antihypertensives on the day of surgery.

Most dysrhythmias seen in the PACU have an underlying cause that is unrelated to myocardial injury (Odom-Forren, 2014). A common dysrhythmia after surgery is sinus tachycardia (rate >100 beats/min in an adult). Frequent causes include pain, hypoxemia, hypovolemia, increased temperature, and anxiety. The underlying cause of the dysrhythmia is treated. Propranolol, metoprolol, or esmolol may be given. Sinus bradycardia (heart rate <60 beats/min in an adult) also is a common dysrhythmia in the PACU. Causes include hypoxemia, hypothermia, high spinal anesthesia, vagal stimulation, and some medications commonly given during or after surgery. The underlying cause of the bradycardia is treated. Atropine is the drug of choice to increase heart rate, and usually no other treatment is required. Temporary or permanent pacemakers sometimes are required.

Premature ventricular contractions (PVCs) are represented by wide, bizarre-looking QRS complexes. The most common causes in the postoperative period are hypoxemia and hypokalemia, which are treated. Often, if cardiac disease or hypotension is not present, PVCs do not require medication.

Treatment of dysrhythmias begins with determining and removing the source of the problem. The urgency of treating cardiac dysrhythmias depends on the patient’s underlying condition; dysrhythmias are most harmful in patients who have a history of coronary heart disease (Nicholau, 2009). Antidysrhythmic drugs, resuscitation equipment, and monitoring equipment should be immediately available.

Postoperative hypothermia, defined as a temperature less than 96.8° F (36° C) (Hooper et al., 2010), continues to be a widespread PACU problem. While hypothermia may not be life threatening, it does cause physiologic stress. Hypothermia can prolong recovery time and contribute to postoperative morbidity. Especially vulnerable to the effects of hypothermia are the elderly and children 2 years old or younger. Other risk factors include female gender, burn patients, patients who received general anesthesia with neuraxial anesthesia, low ambient temperature of the OR, length and type of surgical procedure, cachexia, significant fluid shift, and use of cold irrigants. The prevention and management of unplanned perioperative hypothermia remain a national priority in preventing surgical site infection, and it has been designated as an SCIP quality measure (Langham et al, 2009; TJC 2013).

Assessing the need for prewarming begins preoperatively. Preventive warming measures are begun for normothermic patients and active warming measures instituted for hypothermic patients (Hooper et al, 2010).

Prevention of heat loss continues in the OR. Under general anesthesia patients do not produce heat and depend on ambient temperature. Prevention of heat loss includes increasing the ambient temperature in the OR, providing the patient with warm blankets on arrival in the OR, and using draping techniques that minimize exposure during the procedure. Heated humidifiers and fluid warmers add heat. A common device to prevent hypothermia in the OR is a forced-air warming device (Figure 10-5).

In the PACU tremendous demands are made on the body when the patient shivers. Shivering can increase the need for oxygen by 300% to 400%. Hypothermic patients should have oxygen therapy initiated immediately on admission. For a patient with a healthy heart, there may be no harmful effects. For a patient with coronary artery disease or cardiomyopathy, however, decompensation can occur. Perioperative hypothermia has been associated with increased incidence of cardiac incidents including myocardial ischemia and myocardial infarction (Nicholau, 2009).

Other problems associated with hypothermia include intravascular volume loss attributable to a fluid shift from the extracellular space, probably related to vasoconstriction (Reynolds et al, 2008). As the patient begins to rewarm, vasodilation follows, and the patient can require large amounts of IV fluids to avoid hypovolemia. The central nervous system is depressed by hypothermia. A cold postanesthesia patient remains more anesthetized than a warm patient while recovering. Nitrogen loss and hypokalemia can cause a predisposition to wound infection. Impaired wound healing and surgical site infection have been linked to hypothermia (Paulikas, 2008).

Hypothermia slows metabolism and alters the effects of some anesthetic drugs. Of special interest is the prolonged elimination of muscle relaxants in hypothermic patients. Clotting abnormalities can occur. Platelet activity declines, and fibrinolysis increases with hypothermia; both conditions enhance the tendency to bleed (Hooper, 2013).

Rewarming is a priority for the postoperative patient. Wet and cold gowns and blankets are removed, and warm, dry gowns and blankets are applied to the head and body. Several external rewarming techniques are available. Application of warm cotton blankets has been a PACU tradition. Warm blankets are applied every 5 to 10 minutes until the patient is normothermic. Cotton blankets gradually increase the patient’s temperature. They do not actively heat patients, however, and warming can be a slow process. Forced-air warming devices are effective in rewarming patients. They produce a thermal-focused environment that transfers heat by blowing warm air through a plastic and tissue paper blanket that covers the patient. Forced-air warming devices are standard hypothermia treatment in PACU settings. This is an evidence-based nursing initiative that actively decreases hypothermia (Hooper et al, 2010).

There is some evidence that continuous fluid-circulating blankets or warm-water mattresses, radiant heat lamps, gel pads, and resistive heating work (Hooper et al, 2010). Continuous fluid-circulating blankets may not work as well because the size of the surface area in contact with the heat source is limited. Radiant heat lamps depend on exposure of large areas of body surface and are of limited use to adult patients. Fluid and blood warmers are useful for large volumes of cool fluids, but not to reverse hypothermia. Single strategies such as forced-air warming were more effective at increasing temperature than passive warming as determined by one systematic review; however, combined strategies, including use of preoperative prewarming, use of warmed fluids, forced-air warming, and other active strategies were more effective in vulnerable groups (Moola and Lockwood, 2011).

Studies have explored the best method to obtain accurate temperatures in the PACU when invasive core temperature measures (e.g., pulmonary artery, distal esophagus, nasopharynx, and tympanic membrane) are unavailable. A study comparing eight noninvasive techniques to bladder temperature (Langham et al, 2009) concluded that the most accurate method for routine postoperative temperature monitoring was via electronic oral temperature devices.

Hyperthermia may indicate an infectious process, sepsis, or a serious hypermetabolic process—malignant hyperthermia (MH). MH is a life-threatening emergency that is genetic in origin (Rosero et al, 2009). It is triggered by volatile anesthetic agents and the depolarizing muscle relaxant succinylcholine. Death may ensue unless MH is immediately recognized and treated (see Chapter 5 for a discussion of MH). Some institutions have crisis checklists in the PACU and OR to guide staff step by step thorough emergencies such as MH (Arriaga et al, 2012).