Transferring children from the operating room to the PACU requires a stable airway, adequate oxygenation and ventilation, stable heart rate and blood pressure, and adequate pain control (Fig. 42-4: Position of the child after tracheal extubation in preparation for transfer to the postanesthesia care unit and the pediatric intensive care unit).
- PACU Complications. Children >8 years of age vomit more than twice as frequently as those <8 years, but respiratory complications in infants <1 years of age occur twice as frequently as in those >1 year of age. Laryngospasm, postoperative stridor, and negative pressure pulmonary edema occur both during induction of anesthesia and during or after emergence from anesthesia.
- Oxygen Desaturation
- Unrecognized hypoxia may lead to deterioration in the child's clinical status and lead to sudden bradycardia and cardiac arrest.
- Continuous monitoring of the child's oxygen saturation in the PACU is essential to provide an early warning sign (minimum acceptable oxygen saturation in the PACU is 94%).
- Emergence Agitation. The introduction of sevoflurane and desflurane anesthesia in children has caused a recrudescence of emergence agitation (also known as emergence delirium).
- Vomiting in the PACU and after hospital discharge has decreased dramatically with the introduction of prophylactic antiemetics for children at risk for PONV. IV dexamethasone (0.0625–0.15 mg/kg [maximum 10 mg]) and ondansetron (0.05–0.15 mg/kg) reduce the perioperative incidence of PONV by up to 80% or more.
- Postoperative Pain
- Regional anesthesia is usually performed during general anesthesia in children (except in older adolescents) using a direct nerve block or nerve stimulation or more recently ultrasound guidance.
- When regional block is unsuitable, impractical, contraindicated, or refused by the parents, opioids, NSAIDs (diclofenac, tramadol, ibuprofen, and acetaminophen) and ketamine may be used.