The post anesthesia care unit (PACU) is where patients recover after surgery and anesthesia. It is equipped to monitor unstable patients while providing comfort for stable patients. Upon arrival, the anesthesiologist provides a report to the PACU nurse. Vital signs are closely monitored for complications like low oxygen, breathing issues, or irregular heart rate. Standard criteria govern PACU design, staffing, and discharge of stable patients once criteria are met, such as a score of 9 or higher on the Postanesthetic Discharge Scoring System. Common complications include nausea, breathing problems, and low blood pressure, which nurses are trained to quickly identify and treat.

1. Post Anesthesia Care Unit
Presenter: Robert, MD
Resident II, Anesthesiology.

2. Outline
 Introduction to post anesthesia care unit(PACU).
 Standard of post anesthesia care unit
 Hands-off of patient at PACU.
 PACU admission report.
 Complications at post anesthesia unit.
 Discharge criteria's at post anesthesia unit.

3. Introduction to post anesthesia unit
 The post anesthesia care unit is a special room/place nearby operating room
designed and staffed to monitor and care for patients who are recovering from the
immediate physiologic effects of anesthesia and surgery.
 To serve this unique transition period, the unit is equipped to resuscitate unstable
patients while providing a tranquil environment for the “recovery” and comfort of
stable patients.
 The exception is critically ill patients and those who are intubated, who may
bypass the PACU and be recovered directly in an intensive care unit.
 Its location in close proximity to the operating rooms facilitates rapid access to
anesthesiologists for consultation and assistance.

4. Post anesthesia care unit…
 The PACU is staffed by specially trained nurses skilled in the prompt recognition of
postoperative complications.
 On arrival to the PACU, the anesthesiologist provides the PACU nurse with
pertinent details of the patient’s history, medical condition, anesthesia, and surgery.
 Particular attention is directed toward monitoring oxygenation (pulse oximetry),
ventilation (breathing frequency, airway patency, and circulation (systemic blood
pressure, heart rate, electrocardiogram [ECG]).
 Vital signs are recorded as often as necessary but at least every 15 minutes while
the patient is in the unit.

5. Standards of post anesthesia care unit
 PACU Design.
 Size.
 Ideal 1.5 PACU bed for every operating room
 120 square foot per patient
 Minimum of 7 feet between bed.
 Facilities.
 Fowler’s cot with side rails
 Piped oxygen, vacuum and air, and airway equipment's.
 Multiple electric outlets, good light and large doors

6. Standard of post anesthesia care unit
 Location
 Should be located near an operating theatre.
 Immediate access to x ray blood bank and clinical lab
 Central nursing station
 Requires good ventilation.
 An open ward with at least one isolation room
 It should be sound proof,, painted with soft color, isolated and these features will help to
remove anxiety to patients.

7. Standards of postanesthesia care unit..
 PACU staffing
 One nurse for one patient in the first 15 mins
 Then one nurse for every two patients
 Anesthetist remain responsible for managing the patient at PACU
 Other ancillary staffs , like technician and runners.

8. The standards for post anesthesia care
 Practice Standards delineate the required obligation of minimal care in the clinical
setting.
 The Standards for Post anesthesia Care are updated on a regular basis to keep up
with changing practice parameters and technologic advances.
 There are fives (5) most recent updated standards practice for post anesthesia
care by ASA.

9. Standards for post anesthesia care
I. All patients who have received general anesthesia, regional anesthesia, or
monitored anesthesia care shall receive appropriate post anesthesia management.
II. A patient transported to the PACU shall be accompanied by a member of the
anesthesia care team who is knowledgeable about the patient’s condition. Also
The patient shall be continually evaluated and treated during transport with
monitoring and support appropriate to the patient’s condition.
III. Upon arrival in the PACU, the patient shall be reevaluated and a verbal report
provided to the responsible PACU nurse by the member of the anesthesia care
team who accompanies the patient.

10. Standards for post anesthesia care
I. The patient’s condition shall be evaluated continually in the PACU. The patient
shall be observed and monitored by methods appropriate to the patient’s medical
condition. Particular attention should be given to monitoring oxygenation,
ventilation, circulation, level of consciousness, and temperature. During recovery
from all anesthetics, a quantitative method of assessing oxygenation such as pulse
oximetry shall be employed in the initial phase of recovery.
II. A physician is responsible for the discharge of the patient
from the PACU.

11. Hands-off of patients at PACU
 Handoffs is defined as points in a patient's care when responsibility for well-being
is transferred between individual providers and/or care teams.
 Such transitions of care occur at multiple stages in the perioperative process,
including handoff to another anesthesia provider in the operating room (OR) and
eventual patient transport with monitoring to a separate physical location for
handoff to personnel in the post-anesthesia care unit.
 For all phases of perioperative care, we employ a formal handoff protocol that
emphasizes standardization of this process, including both verbal and written
communication.
 The SBAR (situation, background, assessment, recommendation) model has been
used successfully by allied health professionals, such as those in nursing.

12. Steps during hands-off to PACU
 Pre-handoff – Sender organizes and updates information in preparation for the
handoff.
 Arrival – Work stopped in order to conduct the handoff. Ideally, time is protected
for the handoff to occur.
 Dialogue – An exchange takes place between the sender and the receiver. Ideally,
this is verbal but it may be written/electronic as well.
 Post-handoff – The receiver of patient information integrates the new information
and assumes care of the patient.

13. OP room to PACU hands-off
 Review of pertinent medical history, allergies, and the surgical procedure performed
 Total dose and last timing for opioids, muscle relaxants, and antibiotics
 Total fluids administered including colloids and blood products
 Critical intraoperative laboratory values if these were obtained (eg, hemoglobin or hematocrit;
glucose and potassium levels; last activated whole blood clotting time if heparin was administered)
 Airway management and any difficulties
 Prophylactic medications previously administered for postoperative nausea and vomiting
 Any untoward intraoperative events
 The plan for postoperative analgesia
 Discussion of disposition after PACU discharge (eg, to home, a hospital ward, or an intensive care
unit [ICU] bed)

14. PACU admission report
 Preoperative history/procedure.
 Medication allergies or reactions
 Pertinent earlier surgical procedures
 Underlying medical illness
 Chronic medications
 Acute problems (eg, ischemia, acid-base status, dehydration)
 Pre medications (eg, antibiotics and time given, beta-adrenergic blockers, antiemetics)
 Preoperative pain control (eg, nerve blocks, adjunct medications, narcotics)
 Preoperative pain assessment (chronic and acute pain scores)
 NPO status

15. PACU admission report…
 Intraoperative factors
 Surgical procedure and type of anesthetic drugs.
 Type and difficulty of airway management
 Relaxant/reversal status
 Time and amount of opioids administered
 Type and amount of intravenous fluids administered
 Estimated blood loss and urine output.
 Unexpected surgical or anesthetic events
 Intraoperative vital sign ranges and laboratory findings
 Drugs given (eg, steroids, diuretics, antibiotics, vasoactive medications, antiemetics

16. PACU admission report
 Assessment and report of the current status.
 Airway patency
 Ventilatory adequacy
 Level of consciousness and level of pain.
 Heart rate and heart rhythm
 Endotracheal tube position
 Systemic pressure and intravascular volume status
 Function of invasive monitors
 Size and location of intravenous catheters
 Anesthetic equipment (eg, epidural catheters, peripheral nerve catheters)
 Overall impression

17. PACU admission report…
 Postoperative instructions.
 Expected airway and ventilatory status
 Acceptable vital sign ranges
 Acceptable urine output and blood loss
 Surgical instructions (eg, positioning, wound care)
 Anticipated cardiovascular problems
 Orders for therapeutic interventions
 Diagnostic tests to be secured
 Therapeutic goals and end points before discharge
 Location of responsible physician

18. Incidence of complications at PACU
 Most common problem in the post-anesthesia care unit (PACU) is postoperative
nausea and vomiting.
 Other complications involved the upper airway or cardiovascular system (eg,
hypotension, dysrhythmias, hypertension and other major cardiac events.
 In a 2002 review of 419 PACU incident reports from the Australian Incident
Monitoring Study (AIMS), 44 percent were upper airway or respiratory
complications, while 24 percent were cardiovascular complications.

19. Postoperative nausea and vomiting
 Postoperative nausea and vomiting (PONV) is the most commonly treated problem
in the immediate postoperative period.
 Control of PONV is a necessary criterion for discharge from the post-anesthesia
care unit (PACU), regardless of whether the patient is going home or to a hospital
ward.
 PONV usually resolves or is treated without sequelae, but may require
unanticipated hospital admission and delay recovery room discharge.
 In addition, vomiting or retching can result in wound dehiscence, esophageal
rupture, aspiration, dehydration, increased intracranial pressure, and
pneumothorax.

20. Postoperative nausea and vomiting…
 The molecular and neural mechanisms by which drugs and toxins, including
anesthetics and opioids, cause nausea and vomiting are complex and incompletely
understood.
 Both opioids and inhalation anesthetics may cause nausea and vomiting by
stimulation of the area postrema at the base of the fourth ventricle in the medulla.
 The area postrema then communicates with the central pattern generator via
dopamine and serotonin to trigger the vomiting reflex.

21. Anesthetic risk factors on PONV
 Anesthetic technique – General anesthesia is associated with a higher incidence
of PONV compared with purely regional anesthesia.
 Regional anesthesia, in both adults and children, may reduce PONV by reducing
opioid administration for postoperative pain.
 Volatile anesthetics versus total intravenous anesthesia – The use of volatile
anesthetics is an important risk factor for PONV.
 In a study of 1180 surgical patients, those randomly assigned to receive potent
inhalation anesthesia with isoflurane, enflurane, or sevoflurane had a higher risk of
PONV compared with propofol, which has antiemetic properties (OR 2.4, 2.3, and
2.3, respectively).

22. Anesthetic risk factors on PONV…
 The use of total intravenous anesthesia (TIVA) rather than volatile anesthetics may
also reduce hospital length of stay for patients or procedures that are at high risk
for PONV or surgical complications related to vomiting.
 Duration of anesthesia – Longer duration of anesthesia with volatile anesthetics
may increase the risk of PONV.
 In addition to the increase in dose of anesthetics, longer procedures tend to be
more invasive, and tend to require administration of larger doses of postoperative
opioids than shorter procedures.
 Non anesthetic risk factors includes; female gender, nonsmoker and previous
history of motion sickness or PONV.

23. Risk factors for PONV in children

24. Prevention of postoperative PONV
 A multimodal, opioid-sparing or opioid-free strategy for effective perioperative
pain control.
 Modification of anesthetic technique and medications used, administration of
antiemetics.
 Adequate hydration – In clinical practice, decisions regarding IV fluid
administration in adults are usually based on factors other than the risk of PONV.
 Dexamethasone may be beneficial because of a direct antiemetic effect and by
reducing postoperative pain and the need for postoperative opioids. Lower doses
of dexamethasone may be required for PONV prophylaxis than for pain relief

25. Respiratory complications
 Bronchospasm and/or anaphylaxis in the post-anesthesia care unit (PACU)
 Other causes of respiratory insufficiency in the PACU are upper airway obstruction,
lower airway or pulmonary complications, or hypoventilation due to a depressed
level of consciousness or neuromuscular weakness.

26. Cardiovascular complications
 Cardiovascular problems in the post-anesthesia care unit (PACU) include;
 Hypotension,
 Hypertension.
 Cardiac arrhythmias.
 Myocardial ischemia, and decompensated heart failure.

27. Postoperative hypothermia and shivering
 Postoperative hypothermia, defined as a core temperature less than 36°C, is a
detrimental and unpleasant condition that can occur after general and neuraxial
anesthesia.
 The incidence of postoperative shivering may be as high as
66% after general anesthesia.
 Identified risk factors include young age, endoprosthetic surgery, and core
hypothermia.

28. Neuropsychiatry complications
 Intraoperative awareness with recall — Awareness with recall following general
anesthesia refers to intraoperative consciousness with postoperative recall of
events.
 Delayed emergence and emergence delirium — Failure to return to a fully
conscious state in a timely fashion following administration of general anesthesia
may manifest as delayed emergence or emergence delirium.
 Visual disturbance — Corneal abrasion is the most common cause of eye pain
with or without visual disturbance in the postoperative period. Typically, the patient
complains of the sensation of a foreign body in the affected eye.
 Although rare, a patient may awaken from anesthesia with partial or complete loss
of vision (with or without pain), prompting the need for urgent ophthalmologic
consultation.

29. Postoperative delirium
 Postoperative delirium (POD) is defined as an acute and fluctuating alteration of mental
state of reduced awareness and disturbance of attention.
 POD often starts in the recovery room and can occur up to 5 days after surgery. Pain,
hypoxia, electrolytes imbalance, hypoglycemia, medications, indwelling catheter, fecal
impaction and acute urine retention may precipitate the problem.
 Pharmacologic interventions should be reserved and only used in the lowest effective
dose for agitated delirious patients when other interventions have failed and the
patients pose a substantial harm to themselves or others.
 The medication of choice in this case is haloperidol starting at 0.5 to 1 mg IM/IV.

30. Discharge from the post anesthesia care
unit
 Standard discharge criteria — Discharge criteria are designed to determine a patient's
readiness to safely leave the post-anesthesia care unit (PACU).
 Several scoring systems have been developed, both for the Phase I and Phase II PACU
periods.
 Postanesthetic Discharge Scoring System (PADSS).
 Vital signs.
 Activity level.
 Nausea or vomiting and pain.
 Surgical bleeding, and intake and output
 Criteria for discharge to home typically include a PADSS score ≥9.
 Another example is the Aldrete score, which includes five elements (activity, respiration,
circulation, consciousness, oxygen saturation).

31. PACU discharge criteria's
Postanesthetic discharge scoring system
Vital signs
2 = BP + pulse within 20% preop baseline
1 = BP + pulse within 20-40% preop baseline
0 = BP + pulse >40% preop baseline
Activity
2 = Steady gait, no dizziness, or meets preop level
1 = Requires assistance
0 = Unable to ambulate
Nausea and vomiting
2 = Minimal/treated with PO medication
1 = Moderate/treated with parenteral medication
0 = Severe/continues despite treatment
Pain
Controlled with oral analgesics and acceptable to patient:
2 = Yes
1 = No
Surgical bleeding
2 = Minimal/no dressing changes
1 = Moderate/up to two dressing changes required
0 = Severe/more than three dressing changes required
Score ≥9 for discharge
ht © 2013 Lippincott Williams & Wilkins. www.lww.com.

32. References
 MILLER'S ANESTHESIA, 9th Ed, 2020
 www.uptodate.com.