Post Anesthesia Care Unit (PACU)

Rotation Director (email) Rotation Name David Stoll (stollwil@musc.edu) Post Anesthesia Care Unit (PACU) COURSE OVERVIEW Course Overview (75 100 words describing the course) The Post Anesthesia Care Unit experience is a two contiguous week experience intended to provide the resident with the medical knowledge and clinical experience necessary to manage patients in the immediate postoperative period. The clinical experience will provide management opportunities for both adult and pediatric patients recovering from general anesthesia, conscious sedation, and regional anesthesia. Didactic instruction will consist of informal and guided self-directed study. Formal lectures on post anesthesia care are provided as part of the scheduled lecture series. This rotation challenges the resident to develop an understanding of common complications in the post anesthesia care unit and utilize this knowledge to practice prevention, early recognition and rapid intervention. LEARNING OBJECTIVES Knowledge Knowledge Recall Basic Science Basic Science Practical Knowledge Clinical Knowledge Clinical Knowledge Clinical Knowledge Knowledge Analysis Neurology Cardiac Pulmonary Pain management Controversies Knowledge Synthesis Anesthesia and Surgery Overall care Knowledge Application Airway Pulmonary Cardiac Analgesia Definitive Care Thorough understanding of physiology of all organ systems Thorough understanding of the pharmacology of pertinent drugs Understand the components and requirements of a PACU Understand the admission and discharge criteria for patients Understand the nature of all pertinent surgical procedures Understand comorbidities related to all organ systems Recognize and diagnose different causes for altered mental status Recognize and diagnos arrhythmias, blood pressure disturbances, and ischemia Recognize and diagnose obstruction, hypoventilation, and hypoxemia Understand proper analgesic techniques (regional anesthesia, opioids, and nonopioids) Analyze controversies surrounding blood product, fluid, and glucose management as well as beta blockade Understand how the surgical procedure and anesthesia can affect the patient and exacerbate comorbidities Understand and recognize patients that can be properly discharged from the PACU to home, the hospital floor rooms, or need more intensive care Understand all airway complications relating to difficult airways and surgery involving the airway Apply treatment for obstruction, hypoxemia, hypoventilation Ordering, interpreting, and initiating treatment of arrhythmias and ischemia, including the application of ACLS algorithms for code situations Initiate or maintain appropriate analgesia for post operative patients After recognizing and diagnosing patient problems the resident should be able to initiate treatment and/or facilitate definitive care with the primary team Skills Manage airway obstruction (pharyngeal and/or laryngeal obstruction as well as edema and hematoma) Proficient in the use of multiple intubating devices and techniques including fiberoptic techniques Placement of peripheral and central intravenous access Placement of invasive hemodynamic monitoring devices (arterial lines and pulmonary artery catheters) Massive resuscitation Interpret data from invasive monitors, along with how to use this data in clinical decision-making

Demonstrate proficiency in providing cardiopulmonary resuscitation Demonstrate an understanding of clinical criteria for discharge from the PACU Attitudes Demonstrate respectful attitude toward nursing staff Demonstrate respectful attitude toward surgical team Coordinate and relay concerns about patient to both the surgical team and primary anesthesia team Show compassion for patient concerns and modesty Pleasant communication with the family in all situations and be able to diffuse difficult situations Show compassion in managing common post operative issues, concerns (pain, nausea and vomiting, hunger, thirst)

Patient Care: The resident will develop an understanding of the physiologic changes associated with surgery and anesthesia and the residual effects present in the immediate postoperative period. Early observation and evaluation of recovering patients will allow the resident to comprehend the significance of these changes and recognize, diagnose, and treat common PACU problems. Prevention of common complications through anticipation of associated physiologic changes, early recognition and proactive care are the goal of post anesthesia patient management. Objective 1. Assess, diagnose, and initiate treatment with common PACU emergencies Simulation Lab Interpret laboratory data (cbc, chemistries, arterial blood gases) Interpret radiographic images (Chest radiographs, CT scans) Objective 4. Interpret electrocardiograms Objective 5. Demonstrate proficiency in providing cardiopulmonary resuscitation Simulation Lab Objective 6. Successfully troubleshoot equipment and monitors Simulation Lab Objective 7. Successfully manage a patient s acute and/or chronic pain in PACU and the post-operative period

Medical Knowledge: Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to at the conclusion of the post anesthesia care unit rotation the resident should have an understanding of the following basic science and clinical knowledge and appropriately integrate this knowledge into patient management decisions. Objective 1. Recall and utilize basic science knowledge, including, but not limited to: Physiology = respiratory, cardiovascular, central nervous system, renal, gastrointestinal, thermoregulation, shivering, hyperthermia, and acidbase balance. Written test Recall and utilize basic science knowledge, including, but not limited to: Pharmacology = Opioids and opioid antagonists, benzodiazepines and benzodiazepine antagonists, NSAIDS, muscle relaxants and reversal agents, inotropes and vasodilators, local anesthetics, inhalational anesthetic agents, and anti-emetics. Recall and apply clinical science knowledge, including, but not limited to: A. PACU admission criteria B. PACU discharge criteria including, discharge to floor and home, unanticipated admission planning, unanticipated ICU transfer, acute care unit (ACU) transfer, fast-tracking, phase I and II recovery, essentials of PACU admission report and discharge/transfer report C. Evaluation and management of common PACU problems such as: respiratory = airway obstruction, hypoventilation, stridor, wheezing, aspiration, pulmonary edema, post-obstructive, volume overload, hypoxemia cardiovascular = hypertension, hypotension, myocardial ischemia, dysrhythmias, hemorrhage nausea and vomiting renal problems = oliguria, anuria, polyuria, hematuria, urinary retention electrolyte and metabolic abnormalities coagulopathy fluid management = crystalloid vs. colloid blood transfusion reaction delayed awakening postoperative agitation and delirium Written test Written test Simulation Lab

increased intracranial pressure postoperative seizure prolonged neuromuscular blockade hypothermia hyperthermia malignant hyperthermia anaphylaxis/allergic reaction postoperative pain management = PCA, parenteral opioids, NSAIDS, opioid agonist/antagonists continuous peripheral regional techniques = neuroaxial blockade ventilator management corneal abrasion protocol treatment of shivering Practice-based Learning and Improvement: Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning Utilization of the CQI process to improve patient safety and personal performance. Active participation in furthering their knowledge by attending organized educational activities Objective 1. Objective 4. Self-analyze his or her practice and compare their practice to that of their peers. Residents should use this assessment to perform continual practice-based improvement. Understand of the role of information technology in th practice of anesthesia and utilize this technology for self-education and management of patient information. Accept constructive criticism from faculty and peers with demonstrated responsiveness by reflective clinical performance and practice improvement Incorporate evidence-based practice into knowledge base and clinical performance Utilize the CQI process to improve patient safety and personal performance. Actively participate in furthering their knowledge by attending organized educational activities

Interpersonal and Communication Skills: Residents must be able to demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families and professional associates. Residents should develop: Objective 1. Objective 4. Objective 5 Communicate skills that result in effective information exchange between anesthesia providers, nursing staff, peers, attending physicians, and surgeons Establish therapeutic doctor-patient relationships through appropriate, compassionate patient interactions Recognize and overcome common barriers to effective communication Demonstrate verbal, non-verbal and written skills to accurately communicate patient care information Adequately protect patient confidentiality and their rights in all levels of communication concerning patient information Deliver organized presentations of history and physical examinations, differential diagnosis, and proposed management to the attending anesthesiologist Nursing staff evaluations Nursing staff evaluations Nursing staff evaluations Nursing staff evaluations

Professionalism Residents must demonstrate commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to demonstrate Objective 1. Commit to carrying out professional responsibilities, adhere to ethical principles, demonstrate sensitivity to a diverse patient population Understand of the role of the anesthesiologist in the management of patients recovering from anesthesia and practice within the guidelines of the department, the institution and the American Society of Anesthesiologists Understand HIPPA regulations as they pertain to the management of patient care data Objective 4. Demonstrate compassion and respect for patients and their families expectations and needs Interact with colleagues, peers and staff in a respectful and conscientious manner

Systems-based Practice Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Objective 1. Understand the flow of patients through the PACU Objective 4. Understand how other areas or systems within the institution impact patient flow through the PACU. Demonstrate the ability to coordinate patient care in order to meet the needs of the patient, surgical team, nursing staff and institution Form effective relationships with other members of the health care team to provide care that is of optimal value and quality

TEACHING METHODOLOGIES Students on this rotation will be expected to achieve and comprehend the learning objectives through the following methodologies and activities: Various lectures Simulated scenarios Daily direct one-on-one teaching at the bedside with attendings Global evaluation scoring system by the faculty Director of PACU 360 0 evaluation: Nursing staff evaluation of professionalism, interpersonal communication skills, and system based practice and general patient care interactions. Self directed teaching = material provided by Dr. Stoll at end of rotation PATIENT ENCOUNTERS Residents on this rotation will be expected to work up and/or manage the minimum number of patients/cases with the specified conditions as listed below: (e.g., 10 craniotomies, 20 vaginal deliveries with CLE, etc.) Number Patient Condition / Case 10 Respiratory Compromise 15 Hemodynamic abnormality 30 Pain Control 10 Post Operative Nausea and Vomiting FEEDBACK Please identify when and how the student will receive feedback on his/her performance. Daily Written Final Written Verbal Verbal

Educational Resources: Residents are encouraged to read the general PACU chapters in their regular anesthesia textbooks. Review of the scheduling cases for the following day can help guide daily reading. Recommended Reading: 1. Postanesthesia Care. From: Anesthesiology, ed: Morgan, Mikhail & Murray. 2. Postanesthesia Recovery. Mecca RS. From: Clinical Anesthesia, ed. Barash, Cullen, Stoelting. 3. Optimal Postoperative Analgesia. Ballantyne J, Carwood C. From: Evidence-Based Practice of Anesthesiology, ed. Fleisher LA. 4. Recovery Management of the Healthy Patient. From: Oyos TL, Dull DL. From: Principles and Practice of Anesthesiology, second edition. Longnecker DE, Tinker JH, Morgan GE. 5. Postanesthesia Care Unit. Rosenfield BA, Oyos TL. From: Principles and Practice of Anesthesiology, second edition. Longnecker DE, Tinker JH, Morgan GE. 6. Acute Postoperative Pain Management. Ferrante FM. From: Principles and Practice of Anesthesiology, second edition. Longnecker DE, Tinker JH, Morgan GE. 7. Pulmonary Complications of Anesthesia. Geer RT. From: Principles and Practice of Anesthesiology, second edition. Longnecker DE, Tinker JH, Morgan GE. 8. Hyperthermia and Hypothermia. Karan SM, Lojeski EW, Muldoon SM. From: Principles and Practice of Anesthesiology, second edition. Longnecker DE, Tinker JH, Morgan GE. 9. General versus Regional Anesthesia. Kehlet H. From: Principles and Practice of Anesthesiology, second edition. Longnecker DE, Tinker JH, Morgan GE. 10. Postanesthesia Care Recovery and Management. Kapur PA. From: The Ambulatory Anesthesia Handbook, ed. Twersky RS. 11. Discharge Process. Chung F.. From: The Ambulatory Anesthesia Handbook, ed. Twersky RS. 12. ASA refresher courses: Challenges in the PACU. http://www.asahq.org/rcls/rcls-src/265- Kapur.pdf 13. ASA refresher courses: Criteria for discharge of the Ambulatory surgical patient. http://www.asahq.org/rcls/rcls-src/275-twersky.pdf 14. ASA Practice guidelines for post anesthesia care: Anesthesiology 2002; 96: 742-752. http://www.asahq.org/publicationand Services/standards/Postanessthesia.pdf 15. ASA Practice guidelines for acute pain management in the perioperative setting. http://www.asahq/rcls/rcls-src/224-todd.pdf 16. MUSC Anesthesia Manual (updated Nov 2007) SUBMITTED BY Today s date