What is the appropriate nursing care for patients in the Post-Anesthesia Care Unit (PACU) after undergoing Deep Inferior Epigastric Perforator (DIEP) flaps?

PACU Nursing Care for Post-DIEP Flap Patients

Patients recovering from DIEP flap breast reconstruction require intensive one-to-one nursing observation in the PACU with continuous monitoring of flap perfusion, hemodynamic stability, and aggressive multimodal pain management until they achieve full consciousness, airway control, and cardiovascular stability. 1

Initial PACU Assessment and Monitoring

Standard Vital Sign Monitoring

• Continuous pulse oximetry, non-invasive blood pressure, ECG, and capnography (if airway device in place) must be maintained until full recovery from anesthesia 1
• Monitor and document at minimum: level of consciousness, airway patency, respiratory rate and adequacy, oxygen saturation, blood pressure, heart rate and rhythm, core temperature 1
• Record pain intensity on an agreed scale, nausea/vomiting status, IV infusions, drugs administered, and surgical drainage volume 1

DIEP Flap-Specific Monitoring

• Assess flap perfusion frequently through clinical examination (color, temperature, capillary refill, turgor) - this is critical for early detection of vascular compromise
• Monitor surgical drain output volume and character from both abdominal donor site and breast recipient site 2
• Maintain normothermia using patient warming devices as hypothermia can compromise flap perfusion 1

Staffing Requirements

• One-to-one observation by a registered PACU practitioner or trained staff member is mandatory until the patient regains airway control, respiratory and cardiovascular stability, and can communicate 1
• An anaesthetist must be immediately available for PACU patients at all times 1
• At least one staff member present must be certified in Advanced Life Support 1

Pain Management Protocol

Immediate Postoperative Period

• No patient should be discharged from PACU until pain control is satisfactory 1
• Most DIEP patients (74.9%) require patient-controlled analgesia (PCA) for the first 2 postoperative days 3
• PACU nurses must be specifically trained in managing patients with PCA, epidurals, spinals, and peripheral nerve blocks 1

Identifying High-Risk Pain Patients

• 25% of DIEP patients are "non-responders" who require PCA beyond postoperative day 3 - these patients have higher pain scores on day 1, higher total morphine use, and longer hospital stays 3
• Patients undergoing immediate (versus delayed) reconstruction are more likely to be non-responders 3
• Early identification allows for protocol modifications and prevents prolonged recovery 3

Multimodal Analgesia

• Nurse administration of IV analgesics (paracetamol, NSAIDs, opioids) per anaesthetist protocol facilitates rapid pain control 1
• IV opioid administration by nurses should only occur when an anaesthetist is immediately available 1
• All drug syringes must be clearly labeled 1

Airway Management

• If patient arrives with laryngeal mask airway or supraglottic device, the PACU nurse must be specifically trained in its management and removal 1
• Use oropharyngeal airways or bite blocks to minimize upper airway obstruction risk and prevent post-obstructive pulmonary edema 1
• Tracheal tube removal is the anaesthetist's responsibility but may be delegated to appropriately trained PACU staff who accept this responsibility 1
• An anaesthetist must be immediately available if problems occur during airway device management 1

Nausea and Vomiting Control

• Postoperative nausea and vomiting must be satisfactorily controlled before ward discharge 1
• Administer antiemetics per protocol as these patients often have prolonged operative times increasing PONV risk

Discharge Criteria from PACU

Patients must meet ALL of the following minimum criteria before discharge: 1

• Fully conscious, able to maintain clear airway with protective reflexes intact
• Breathing and oxygenation satisfactory
• Cardiovascular system stable with no unexplained cardiac irregularity or persistent bleeding
• Pulse and blood pressure approximate normal preoperative values or within acceptable parameters
• Peripheral perfusion adequate
• Pain and postoperative nausea/vomiting adequately controlled
• Core temperature acceptable

Common Pitfalls and Considerations

Avoid Premature Discharge

• Do not allow staffing levels or bed pressure to influence observation frequency or discharge timing - life-threatening complications can occur during recovery 1
• If discharge criteria are not met, patient must remain in PACU and anaesthetist informed 1

Enhanced Recovery Protocols

• Modern ERAS protocols for DIEP flaps can reduce hospital stay to 3-4 days without increasing complications 2, 4
• Some centers safely discharge DIEP patients within 23 hours using modified protocols with local anesthesia, microfascial techniques, and prophylactic anticoagulation 5
• However, standard PACU monitoring and discharge criteria remain unchanged regardless of planned length of stay 1

Documentation

• Record patient identification (last name, first name, date of birth, NHS/medical record number), admission time, fitness for discharge time, actual discharge time, and destination 1
• Preferably use automatic recording systems networked with theatre systems 1