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Delayed Emergence
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 | If return to consciousness after cessation of the anesthetic does not return within 20 to 30 minutes prompt attention is required to ascertain possible reversible causes and intervene if possible. |
| Failure to emerge can by classified as due to drug effects, metabolic disorders, or neurologic disorders (in that order). First consider whether there are residual volatile anesthetic agents, whether there significant amounts of narcotics have been administered and the patient is not "too comfortable." Also consider the role of sedative that may have been take pre-operatively, possible residual muscle relaxants, or intoxication with street drugs or alcohol. Metabolic disorders which cause delayed emergence include, you guesed it, hypoxemia, hypercarbia, acidosis, hypoglecemia, hyponatremia, underlying organ dysfunction such as liver failure, and severe hyperthermia such as malignant hyperthermia. |
| Finally, if the above causes have been ruled out, consider neurologic disorders such a cerebral ischemia, hemorrhage, or embolism, a seizure disorder, or pre-existing obtundation |
| Once discharge criteria are met the patient may be discharged from the PACU to their floor bed or to complete their recovery in a day surgery unit. Below are examples of discharge criteria. |
| GUIDELINES FOR DISCHARGE EVALUATION FROM A PACU |
| General condition Oriented to time, place, and surgical procedure |
| Responds to verbal input and follows simple instructions |
| Acceptable color without cyanosis, splotchiness, or paleness |
| Adequate muscular strength and mobility for minimal self-care |
| Absence or control of specific acute surgical complications (e.g., bleeding, edema, neurologic weakness, diminished pulse) |
| Suitable control of nausea and emesis |
| Destination unit appropriate for patient's status |
| System blood pressure Within ± 20% of resting preoperative value |
| Heart rate and rhythm Relatively constant for at least 30 min |
| Resolution of any new dysrhythmia |
| Acceptable intravascular volume status |
| Any suspicion of myocardial ischemia rectified |
| Ventilation and oxygenation Ventilatory rate greater than 10, less than 30 breathsomin-1 |
| Forced vital capacity approximately twice tidal volume |
| Adequate ability to cough and clear secretions |
| Qualitatively acceptable work of breathing |
| Airway maintainance Protective reflexes (swallow, gag) intact |
| Absence of stridor, retraction, or partial obstruction |
| No further need for artificial airway support |
| Control of pain Ability to localize and identify intensity of surgical pain |
| Adequate analgesia, at least 15 min since last opioid |
| Safe, appropriate orders for postdischarge analgesics |
| Renal function Urine output >30 mloh-1 (catheterized patients) |
| Appropriate color and appearance of urine, evaluation of |
| hematuria |
| Follow-up orders in re output if spontaneous voiding has |
| not occurred |
| Metabolic/laboratory Acceptable hematocrit level in view of hydration, blood loss, |
| and potential for future losses |
| Suitable control of blood glucose |
| Appropriate electrolyte homeostasis |
| Evaluation of chest radiograph, ECG, and other tests as |
| appropriate |
| Ambulatory patients Ability to ambulate without dizziness, hypotension, or support |
| Suitable control of nausea and vomiting after ambulation |
| Not all criteria will be satisfied by every patient, especially if discharge is to a critical care unit. Clinical judgment must always supersede established guidelines if the patient's condition is less than optimal in a given area. Whenever doubt exists about diagnosis or patient safety, discharge should be delayed. |
| That's a cursory introduction to postoperative care. Are you ready to sign up? |
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