Pediatric Post-anesthesia Care Unit Challenges Update

Abstract

The purpose of this review is to discuss the current management of various challenges the health care provider faces in the pediatric post-anesthesia care unit (PACU). Efforts to ameliorate and manage PACU issues in the pediatric patient continue to evolve as new medications and methods of anesthesia delivery are introduced and incorporated into the perioperative period. In this review, emergence delirium (ED), postoperative nausea and vomiting (PONV), residual neuromuscular blockade, and tracheal extubation in the operating room versus the PACU are addressed. As ED may be self-limited, pharmacologic treatment may only be indicated if there is a concern for patient harm. Midazolam, fentanyl, and propofol have all been shown to be effective in the treatment of emergence delirium. Dexmedetomidine has been shown to decrease the incidence of ED when administered preoperatively or intraoperatively. This has led practitioners to use dexmedetomidine to treat ED in the PACU, though this has not been studied. Postoperative nausea is difficult to assess in the pediatric patient leading to under treatment. In order to capture these children, the BARF score, initially validated for use in oncologic pediatric patients, is validated for use in postoperative pediatric patients 6 years and older. The approach to treating breakthrough PONV in the PACU is guided by the medications administered intraoperatively for prophylactic treatment. Rescue medications from a different class should be selected if fewer than 6 h have passed since the administration of prophylactic antiemetics. Inadequate reversal of neuromuscular blockade intraoperatively results in adverse respiratory events in the PACU. In the past, when maximum doses of reversal agents are administered, the only recourse in the PACU is to provide assisted ventilation. With the introduction of sugammadex, assisted ventilation can be avoided since sugammadex is capable of reversing dense neuromuscular blockade by vecuronium or rocuronium. In the current environment of achieving greater OR efficiency and cost savings, some institutions are moving tracheal extubation from the operating room by trained anesthesiologists to the PACU by trained nurses with physicians immediately available. This practice in two different children’s hospitals is shown to be safe with no greater incidence of adverse respiratory events and with the added benefit of decreasing operating room time. PACU challenges in the pediatric patient continue to occur despite changes in anesthetic practice and introduction of newer medications. It is important to keep abreast of these newer modalities to best manage these PACU conditions.