Common pacu problems

PACU basics: your priorities

• Use an A–E approach (Airway, Breathing, Circulation, Disability, Exposure) and treat problems as you find them.
• Always check: patient identity, operation, anaesthetic type, allergies, comorbidities, airway difficulty, analgesia plan, antiemetics given, antibiotics, fluids/blood loss, drains/blocks, and any intra-op events.
• Know the local escalation route: who to call (anaesthetic registrar/consultant), emergency buzzer, and where airway equipment is kept.
• Oxygen is a treatment: give it when needed, but look for and treat the cause of hypoxia.
• Document clearly: observations, interventions, response, and who was informed.

Airway obstruction (commonest early issue)

• Clues: noisy breathing (snoring/stridor), paradoxical chest movement, falling saturations, agitation or reduced consciousness.
• Immediate actions: call for help early; jaw thrust + head tilt/chin lift; suction; insert airway adjunct (oropharyngeal/nasopharyngeal if appropriate).
• Consider causes: residual anaesthetic/opioids, tongue obstruction, laryngospasm, airway swelling, blood/vomit, tight dressings.
• If persistent or severe: apply high-flow oxygen; consider CPAP; prepare for bag-mask ventilation and re-intubation if needed (get senior help).

Laryngospasm

• Definition: reflex closure of the vocal cords causing partial or complete airway obstruction, often after airway irritation (secretions, blood, extubation, stimulation).
• Signs: inspiratory stridor or silent chest, increased effort, desaturation, bradycardia in severe cases.
• First-line: remove stimulus, jaw thrust, 100% oxygen, tight mask seal with continuous positive airway pressure (CPAP), suction if secretions/blood.
• If not resolving quickly: call senior urgently; deepen anaesthesia if appropriate; be ready for small-dose neuromuscular blocker and re-intubation as per local policy.

Hypoventilation / opioid-related respiratory depression

• Clues: low respiratory rate, rising CO2 (if capnography available), reduced consciousness, small pupils, desaturation (may be late if on oxygen).
• Immediate actions: stimulate, ensure airway open, give oxygen, support ventilation (bag-mask) if needed.
• Check what was given: opioids (morphine/fentanyl/oxycodone), sedatives (benzodiazepines), residual neuromuscular block, regional techniques (e.g., high neuraxial block).
• If opioid toxicity suspected: give naloxone in small titrated doses (aim to restore ventilation, not pain-free wakefulness); monitor for re-sedation (naloxone wears off before many opioids).
• Escalate early if repeated naloxone needed, ongoing ventilatory support, or high-risk patient (OSA, frail, renal failure).

Residual neuromuscular blockade (weakness after GA)

• Clues: shallow breathing, poor head lift/hand grip, weak cough, airway obstruction, inability to maintain oxygenation/ventilation.
• Immediate actions: airway support, oxygen, consider assisted ventilation; call for senior review.
• Check: reversal given? timing? neuromuscular monitoring? interacting drugs (e.g., magnesium, aminoglycosides) and patient factors (hypothermia).
• Management: follow local guidance for additional reversal (e.g., neostigmine/glycopyrronium or sugammadex depending on agent used) and monitor closely.

Hypoxia (low oxygen saturations)

• Think broadly: airway obstruction, hypoventilation, atelectasis, bronchospasm, aspiration, pulmonary oedema, pneumothorax, pulmonary embolism, low cardiac output, anaemia.
• First steps: check probe/trace; increase oxygen; assess airway patency and breathing; listen to chest; check respiratory rate and effort; consider capnography if available.
• Simple measures often help: sit patient up, encourage deep breaths, treat pain, consider CPAP if atelectasis likely and patient cooperative.
• Escalate urgently if saturations remain low despite oxygen, there is stridor, severe wheeze, haemodynamic instability, or reduced consciousness.

Bronchospasm

• Clues: wheeze, prolonged expiration, increased work of breathing, desaturation; may be silent chest if severe.
• Immediate actions: oxygen, sit up, check for airway obstruction, consider nebulised bronchodilator (e.g., salbutamol) and treat triggers (pain, secretions).
• Consider causes: asthma/COPD, aspiration, anaphylaxis, airway irritation, pulmonary oedema.
• Escalate if severe, poor response, or concern for anaphylaxis/aspiration.

Hypotension (low blood pressure)

• Common causes in PACU: hypovolaemia (bleeding/third spacing), vasodilation (anaesthetic, neuraxial block), myocardial ischaemia, arrhythmia, sepsis, anaphylaxis.
• Immediate actions: check cuff/trace; assess pulse, capillary refill, urine output (if catheter), surgical site/drains; give oxygen; ensure IV access patent.
• Treat likely causes: fluid bolus if hypovolaemia suspected; consider vasopressor if vasodilation (seek senior support and follow local policy).
• Look for bleeding: increasing drain output, swelling, tachycardia, pallor, falling Hb (if available). Escalate early.

Hypertension and tachycardia

• Common causes: pain, agitation, hypoxia/hypercapnia, full bladder, shivering, withdrawal, inadequate reversal, anxiety.
• First steps: check oxygenation and ventilation; assess pain score; check temperature; consider bladder distension.
• Treat cause: analgesia, antiemetic, warming, treat hypoxia/hypercapnia; escalate if severe, chest pain, neurological symptoms, or known high-risk cardiovascular disease.

Postoperative nausea and vomiting (PONV)

• Risk factors: female sex, non-smoker, history of PONV/motion sickness, opioids, certain surgeries (e.g., laparoscopy).
• Initial management: sit up, oxygen if needed, treat pain with opioid-sparing approaches, give rescue antiemetic from a different class to what was used intra-op.
• Hydration can help if hypovolaemic; consider checking for hypotension or opioid excess.
• Escalate if persistent vomiting, inability to protect airway, severe abdominal pain/distension, or concern for surgical complication.

Pain problems (including block issues)

• Assess properly: location, severity (score), type (incisional vs crampy/colicky), and whether it matches the surgery.
• First-line: regular paracetamol and NSAID if not contraindicated; add opioids carefully with monitoring; consider local protocols for PCA.
• If regional block used: check expected distribution and time course; consider catheter dislodgement, inadequate block, or local anaesthetic toxicity if symptoms suggest.
• Red flag pain: severe pain out of proportion, new neurological deficit, compartment syndrome features, or chest pain—escalate immediately.

Shivering and hypothermia

• Why it matters: increases oxygen demand, worsens pain, can mimic rigors; hypothermia increases bleeding and delays drug metabolism.
• Check temperature; warm actively (forced-air warming, warmed fluids) and treat pain.
• Consider drug treatment per local policy if distressing/persistent; ensure oxygenation and monitor closely.

Delirium, agitation, and emergence phenomena

• Causes to exclude first: hypoxia, hypercapnia, hypotension, hypoglycaemia, pain, urinary retention, sepsis, stroke, drug effects (opioids/benzodiazepines).
• Approach: calm environment, reorientate, ensure glasses/hearing aids, treat pain and physiological triggers.
• If unsafe agitation: call for senior help; use the lowest effective sedative strategy per local guidance and monitor airway/ventilation closely.

Urinary retention

• Risk factors: neuraxial anaesthesia, opioids, pelvic/urology surgery, older men, long cases, large fluid volumes.
• Clues: suprapubic discomfort, agitation, hypertension, low urine output (if no catheter).
• Management: bladder scan if available; follow local catheterisation protocol; treat pain and review fluids.

Bleeding and haematoma (including neuraxial red flags)

• Look for: increasing drain output, soaked dressings, swelling, tachycardia, hypotension, pallor, dizziness.
• Actions: call surgical team and anaesthetics early; secure IV access, send bloods if requested (FBC/coagulation), consider group and screen/crossmatch per situation.
• Neuraxial patients: new leg weakness, numbness, severe back pain, or bladder/bowel dysfunction are emergencies—urgent senior review and escalation.

Anaphylaxis (rare but critical)

• Clues: sudden hypotension, bronchospasm, swelling/urticaria, difficulty ventilating, cardiovascular collapse; can occur in PACU after antibiotics, latex exposure, or other drugs.
• Immediate actions: call emergency help; ABC approach; high-flow oxygen; lie flat with legs raised if tolerated; start IV fluids rapidly.
• Give adrenaline promptly as per local anaphylaxis guideline; continue reassessment and prepare for airway support.
• Document suspected trigger and ensure referral for allergy testing as per policy.