Download The Intensive PACU: Caring for Complex Patients Beyond

The Intensive PACU:
Caring for Complex
Patients Beyond the OR
Kevin Froehlich MD FRCPC
Anesthesiology, Vancouver Acute
Clinical Assistant Professor
UBC Faculty of Medicine
Post--operative Disposition
Post
Routine
Surgical
Patient
PACU
Surgical
Ward
High Acuity
Unit
Sick
Surgical
Patient
ICU
Case #1
• 50 year-old male booked for an 8 hour
anterior-posterior cervical spine
decompression, instrumentation and
fusion for cervical myelopathy. He has
neurologic symptoms in his upper
extremities and chronic neuropathic pain
on multi-modal analgesic therapy
including Oxycodone 50 mg three times
a day.
Case #2
• 75 year-old man booked for a radical
cystectomy and ileal conduit for bladder
cancer. He has a past medical history for
morbid obesity (BMI 45), IHD with prior
CABG, DM2 on insulin, renal impairment
(Cr 160), and COPD. He was also
diagnosed with severe OSA 1 year prior
but is not compliant with CPAP therapy.
What is the anticipated postpostoperative trajectory for these
patients?
Goals and Objectives
• At the end of this lecture, I hope to establish:
o Why we developed the IPACU at VGH
o How we were able to start the IPACU
o Which patients are suitable for the IPACU and when do we
involve the ICU
o Which department members work in the IPACU
o What are the benefits and downsides to our IPACU model
o How we hope to use our IPACU care model for
development and training
Case #3
• 65 year-old man undergoing left hepatectomy
for HCC from hepatitis C.
• PMHx: HTN, smoker and high cholesterol
• Intraoperative- brisk 2L blood loss requiring 4
units RBC, noradrenaline infusion with transient
ST depression when SBP 55 mmHg
• Case is coming to an end, still on small amount
of vasopressor, with ABG: 7.18/35/145/18, Hb 88
TUBE,
PRESSORS,
INTENSIVE CARE.
OPTION: REACTIVE APPROACH
Extubate in the OR… and hope for the best
Treat hypotension with IV fluid
Hold off on starting any analgesia
Take to PACU, return to the OR, start the
next case, manage care over the phone
• If they fail- ICU has to take them!
•
•
•
•
OPTION: PROACTIVE APPROACH
• Take ventilated and sedated on
vasopressor to PACU
• Investigate:
o
o
o
o
Serial ABGs for acid base status and ventilation titration
Complete blood count for Hb, Plt, coagulation markers, renal function
Troponin and ECG for markers of myocardial ischaemia
Bedside Point of Care Ultrasound Assessment (POCUS) for:
• Volume status
• Basic cardiac function
• Evidence of bleeding
1. We had the real estate….
2. We had the nursing knowknow-how…
3. As a department we had the
desire to do the work…
4. We had
support from
critical care
colleagues…
5. We had a way to fund our work…
“The Critical Care Payment Schedule is
intended to be used by physicians providing
direct bedside care to critically ill and
unstable patients who are in need of intensive
treatment, such as ventilatory support,
haemodynamic support including vasoactive
medications, or prolonged resuscitation.”
What patients are appropriate for
our IPACU and when should we
involve our ICU colleagues?
IPACU-- Definition
IPACU
• a specialized high acuity unit
• goal of optimizing management of
postoperative surgical patients prior to
discharge to either a high dependency unit or
a ward bed
IPACU-- Patient Criteria
IPACU
• IPACU patients generally have no more than 2
systemic medical issues requiring
management beyond the scope of routine
PACU care
• Expectation that all IPACU patients will be well
enough for safe transfer out within 24 hours of
admission
When to consult ICU…
One or more new organ dysfunction:
• Hypoxemic respiratory failure with an Fi02
of >50%
• New initiation of non-invasive ventilation
for reasons other than OSA
When to consult ICU…
One or more new organ dysfunction:
• Shock with persistent or increasing
vasopressors requirements
• Progressive acute renal failure with
persistent oliguria
• Severe delirium or agitation
compromising medical management
Typical IPACU Patients
Patient Comorbidities
Surgical Complexity
• Severe cardiac disease
• Severe respiratory
disease
• Major Pain Problem
• Morbid obesity
• Sleep disordered
breathing
• Thoracic- Pneumonectomy
• Vascular- Open AAA
• Urology- Radical
Cystectomy
• HPB- Liver Resection
• Spine- Major Reconstruction
• Surgical Oncology- HIPEC
Do all members of department
manage patients in the IPACU?
Night Call
Anaesthetist
Day Call
Anaesthetist
19:00
7:00
• Initially had 2 anaesthetists responsible for
IPACU care
• Care was suboptimal
o
o
too many other responsibilities
non-uniform level of interest
• Perioperative Anaesthetist (POA) position
created
o
o
o
Consistency
Individuals with an interest in perioperative medicine
Foundation to build on
7:00
Day Call
Anaesthetist
7:00
Perioperative Anaesthetist
13:00
Night Call
Anaesthetist
21:00
• POA shift is M-F, 13:00-21:00
• Clinical responsibilities fall outside the OR
• Position provides consistency for nurses and
department members, establish plans for all
complex patients to guide overnight care
7:00
What are the benefits and
downsides to the IPACU model?
IPACU Care Model
Benefits
• Efficiency
Off-load the ICU
Short-term ventilation,
vasopressor support
• Analgesia
We are the experts
• Airway management
Difficult extubations
• Professional Development
Training/teaching opportunities
Downsides
• Failure in IPACU- Transfer to
ICU
• Anaesthetist ≠ Intensivist
Diagnosticians
Routine ICU care
• Nursing/resource Intensive
• Non-uniform care
Not all anaesthetists enjoy this work
Multiple handover
Case #1
• 50 year-old male, all day anteriorposterior cervical spine decompression,
instrumentation and fusion. Chronic
neuropathic pain on opioids…
o 3L positive fluid balance
o Opioid/ketamine infusion for whole case
o Plan:
• Emerge to evaluate neurologic status, then sedate
• Ventilate overnight given airway oedema
• Optimize analgesia
• Controlled difficult extubation in 24 hours
IPACU-- the place for ‘Difficult
IPACU
‘Difficult
Extubations’’
Extubations
Case #2
• 75 year-old man booked for a radical
cystectomy and ileal conduit for bladder
cancer.
• PMHx:
o
o
o
o
o
morbid obesity (BMI 45)
IHD with prior CABG
DM2 on insulin
renal impairment (Cr 160)
COPD
o severe OSA but no CPAP
OSA--the postOSA
post-operative
conundrum
• Dr. Swart developed a
PACU order-based OSA
protocol to provide a
practical approach to
the post-op
management of patients
with OSA (diagnosed or
suspected)
Dr. Pieter Swart
• Postoperative Risk Score = 6
• Provides objective numerical score to a challenging problem
• PLAN = Overnight IPACU
Case #3
• 65 year-old man undergoing left
hepatectomy
o 2L blood loss intra-op
o Hemodynamic instability with transient ST depression
o Metabolic acidosis
• Proactive Care in IPACU planned
o Take ventilated and sedated on vasopressor to IPACU
• 2 hours after PACU admission:
o
o
o
o
o
Metabolic acidosis improved with correction of hypovolemia (serial POCUS exam)
No evidence of on-going ischemia, first troponin negative, Hb stable
Wean down noradrenaline and commence epidural analgesia
Wean down sedation for PS ventilation with anticipated extubation in the coming
hour
Overnight in IPACU following extubation for on-going monitoring/care
How we hope to use our IPACU
care model for development and
training…
• Clinical Care
o
Post-operative OSA ward
• Anaesthesia staff
development
o
POCUS training
• Workshops
• Visiting Professors
• Image acquisition
• Image interpretation
• Database
• Anaesthesia training
opportunities
o
o
Perioperative Anaesthesia rotation
for the residents
Perioerative Anaesthesia fellowship
Is the IPACU model a fit for
your institution?
PATIENT
AND
SURGICAL
COMPLEXITY
CRITICAL
CARE
RESOURCES
CASC
• Clinical Academic Services Contract- developed in 2000
• Agreement between VGH Department of Anaesthesia
and the Vancouver Coastal Health Authority
• Health authority collects:
o Fee-for-service billings earned by the department
o Fees earned from the University of British Columbia Faculty of Medicine for the
provision of medical education
• Health Authority pays a set fee for every daily
anaesthesia position- we are accountable to provide
the service