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FUNDAMENTAL PRINCIPLES

Patient recovery and the Learning objectives
post-anaesthesia care unit After reading this article you should be able to:

(PACU) C

C
define what is meant by patient recovery
list the equipment that needs to be available in a post-
Nick Preston anaesthesia care unit (PACU)
C define discharge criteria from recovery
Maggie Gregory C understand a different model of recovery/PACU
C define Association of Anaesthetists of Great Britain and Ireland
minimum standards of monitoring
Abstract
Patient recovery is the time from the end of anaesthesia/surgery to regain-
ing full control of airway reflexes. During recovery immediate postopera-
tive complications may arise. Major complications arise in 3e17% of theatre may output patients faster than they can transit PACU
inpatient surgical procedures. These complications should be managed postoperatively e therefore PACU needs to be able to handle
either in theatre or in a designated recovery area (post-anaesthesia multiple patients from each theatre. This situation is especially
care unit). important for day-case anaesthesia, since the fast turnover of
Keywords PACU; post-anaesthesia care unit; postoperative care; patients will place significant pressure on PACU. It is crucial to
recovery effectively plan theatre lists for the resources available otherwise
any backlog in PACU may hold-up theatres. Close liaison be-
Royal College of Anaesthetists CPD Matrix: 1C01, 1C02, 1D02, 1H01, tween each theatre and the PACU will facilitate good patient
1H02, 1I02 throughput with efficient theatre utilization. The patient in re-
covery will remain the responsibility of the handing over clini-
cian (usually the anaesthetist), until the patient leaves the PACU.

Staffing
Definitions
The PACU needs appropriately trained staff, who are capable of
 Patient recovery e defined as the time from the end of managing airways and postoperative complications. Staffing re-
anaesthesia/surgery to regaining full control of airway quirements will depend on the patient population, but all pa-
reflexes. It includes the management of immediate post- tients should be nursed individually. There will also need to be a
operative complications (pain, nausea, airway obstruction, number of ‘floating’ staff to enable flexibility and management of
vomiting etc). The patient then being in a stable condition emergencies without compromising other individual patients,
can be transferred to an area with reduced staffing such as during such an event. There should also be a named person in
a ward (i.e. not necessarily needing one-to-one nursing charge of the recovery area to liaise and coordinate the flow of
care). Alternatively the patient may be transferred to patients in the recovery area.
another high-care area such as the intensive care unit,
where similar care can be maintained for longer periods.
Audit
 Post-anaesthesia care unit (PACU)/recovery e area
immediately close to theatre, with staff, equipment and There should be regular audits covering the management of pa-
facilities to manage postoperative patients and complica- tients, patient performance of the PACU and patient satisfaction.
tions following surgery. This serves to ensure that healthcare is delivered in the right
way, and contributes to the feedback available for training of
What is a recovery area/PACU? staff in recovery and in theatre service improvement.
Regular team training should take place which should include
A PACU should be a large area with the capacity to manage a
management of emergencies in theatre/PACU. All team members
greater number of patients than can be operated on at any one
should take part. For example an exercise could be provided by
time. There are specifications for size, temperature, humidity, air
doing a simulated event in one theatre using a ‘dummy patient’.
changes and scavenging to be found in Association of Anaes-
Although this would at first seem to detract from operating time,
thetists of Great Britain and Ireland (AAGBI) documentation1 and
it provides a mechanism to ensure safe, whole team training in a
Health Building Note 26.2 The precise size will depend on the
real environment.
length of each operation and the period of recovery needed. Most
patients should normally transit PACU in less than 1 hour. A
Why do we need a PACU?
Following anaesthesia (which may be general or regional)
patients should be transferred from theatre to a recovery area.
Nick Preston BSc (Hons) MBBS FRCA is an ST7 Anaesthetist at North Bristol
Patient recovery may be divided into two stages e Stage 1:
NHS Trust, UK. Conflicts of interest: none declared.
immediately following surgery, where they may be physiolog-
Maggie Gregory MB ChB FRCA is an Anaesthetic Consultant at North ically unstable or have the potential to become so. This re-
Bristol NHS Trust, UK. Conflicts of interest: none declared. quires one-to-one nursing. Stage 2: where the patient is fit

ANAESTHESIA AND INTENSIVE CARE MEDICINE --:- 1 Ó 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Preston N, Gregory M, Patient recovery and the post-anaesthesia care unit (PACU), Anaesthesia and intensive
care medicine (2015), http://dx.doi.org/10.1016/j.mpaic.2015.06.015

airway obstruction and analgesia to be recovery area to be useful both pre. one of these  temperature measurement concepts is the ‘medi-room’. The This information should be documented.e.org/10. be seen by the patients admitting practitioner.  non-invasive blood pressure. intravenous. as direct  breathing e rate. patients may be brought there to holding bays to reduce  oxygen supply and delivery system ward transit times. http://dx. All rights reserved.  capacity dependent on accurate modelling niques and postoperative instructions  reduced ability to deal with unforeseen peaks in workload  other e drains. intracranial etc). The patient will  invasive pressure monitoring capability (arterial. but with good During times of exceptional capacity short-stay high-de- monitoring and vigilance. free flaps  challenges traditional clinical model. central then travel directly to theatre when called for. FUNDAMENTAL PRINCIPLES enough to return to the ward. needed for chest X-ray etc). but also pertinent medi-rooms would still need to be situated immediately near to points raised verbally on handover to recovery staff and then to theatres for anaesthetic cover. ensuring theatre lists are used efficiently.e.and post-theatre. PACUs can also  resuscitation equipment and trolleys stocked have additional functions if they are of sufficient size. AAGBI guidelines for recovery area Other hospital services such as preoperative assessment and cardio-pulmonary exercise testing also provide value in pre- AAGBI minimum standards of monitoring3 should still apply to operative planning and allow risk stratification of patients. The idea behind such rooms is for  capnography the patient to be admitted from a reception area directly into a  mobile monitoring equipment for transferring unstable medi-room. ventilatory parameters if discharge of day-case patients. Namely clinical observations supplemented by: lessens any foreseeable impact on both the patient’s recovery  pulse oximetry and on the PACU.06. preoperative blood  higher recovery staff numbers required pressure. Daily checks/equipment Integrating services This list is by no means definitive and each unit will be able to In the current political and economic climate all areas of add to this. ation and then return directly from theatre to the medi-room. based on local preferences and needs. depth. After PACU discharge criteria are be put in place to be able to support such abilities. have their oper- venous pressure. For  drug cupboards stocked example. heart rate. measure since these complex patients require intensive nursing Centralizing recovery skills into a single area enables good risk and medical care and therefore the appropriate resources need to management of these cases. This should be seen as an emergency procedures1 and require some treatment after anaesthesia.mpaic. staffing and equipment e if this is not done effectively discharge area.1016/j. Patient recovery and the post-anaesthesia care unit (PACU). patients remain at cially at the start of the working day. arterial and central venous pressure  better infection control as individual rooms lines)  cannulation/simple lines could be placed before travelling  past medical history. then there will be a significant impact on the theatre throughput and consequently on patient care. where the patient can change. This the PACU. The patient would then either be discharged home or be transferred to a ward. perioperative tech. The purpose of the PACU is to also possible to place regional anaesthetic block patients in the allow the patient sufficient time to regain full control of airway PACU whilst waiting for the block to fully establish.e. the patient may be transferred back the ward or other training.e.doi. innovative alternatives to  nerve stimulator traditional working practices are being developed. Immediately following an operation.015 . in the reflexes. Anaesthesia and intensive care medicine (2015). craniotomy)  patient privacy/dignity  anaesthetic technique (i. high risk of critical events (Stage 1 recovery). Each day the healthcare are facing significant challenges to become more dy. and to ensure that patients remain physiologically precious and traditionally under-utilized hospital space espe- stable. This includes met. allergies and pre-morbid state to theatre  airway e devices utilized/airway manoeuvres required  less patient transit throughout the hospital. Please cite this article in press as: Preston N. The advantages of such a any further ward staff as needed: distributed recovery model include:  surgical procedure (i. most events can be treated early. The recovery staff would stay with the patient in the medi-room until Information for handover of patients to/from the PACU the immediate patient recovery is complete. for any immediate postoperative complications such meantime completing a short case in theatre.2015. In addition there should be immediate availability of the Distributed recovery/PACU following:  electrocardiography In the quest for better patient care. utilizing the managed. 2 Ó 2015 Elsevier Ltd. anaesthetist and surgeon. It is  suction ANAESTHESIA AND INTENSIVE CARE MEDICINE --:. endotracheal intubation)  patient satisfaction  lines (i. pendency unit (HDU) patients may be accommodated in the Major complications occur in 3e17% of inpatient surgical PACU if resources allow. ventilated The disadvantages of a distributed model include:  circulation e cardiovascular stability. This allows the as nausea/vomiting. additional monitoring (i. recovery area should be checked to confirm: namic and offer the highest value-for-money. Gregory M. rhythm  assumes a rapid discharge possible from medi-rooms  analgesic plan e preoperative pain.

orientated to near pre.who. under 38 C  blankets/forced air warming facilities  discharge location: safe and appropriate area to which  sharps and waste bins (clinical and non-clinical) patient can be transferred. HMSO. Wilson IH.e.2015. Gregory M. Safe surgery saves lives. Last accessed May 2012. 3 AAGBI recommendations for standards of monitoring during anaes- operative level thesia and recovery. org/sites/default/files/postanaes02. 3 Ó 2015 Elsevier Ltd. 2011.g. HDU). FUNDAMENTAL PRINCIPLES  airway trolleys stocked and basic equipment available at  pain/emesis: controlled each bed space (i. Therefore if there are  alarm system to summon help in an emergency.1016/j. theatre documentation complete and relevant  monitoring (blood pressure/oxygen saturation/electrocar. Guedel airways etc)  documentation: analgesic.  telephones Further criteria can be added to the list based on patient type  blood collection system available (e.doi. no ongoing unstable blood loss Oxford. fluid and anti-emetic regimens  breathing circuits prescribed. under 16 (adult popu- lation). monitoring of skin-graft sites etc) and on the individual patient  IT system and procedure.015 .  breathing: respiratory rate over 8. concerns regarding drains/dressing etc then this should be included in the handover to recovery and the ongoing ward staff.  conscious level: rousable to voice.org/10. Oxford textbook of anaesthesia. Please cite this article in press as: Preston N. 3rd edn. 1991. All rights reserved. http://www. although evidence such as the World Health Organi-  range of dressings/drains available zation Surgical Safety checklist4 demonstrate that the entire oper-  access to sluice area ative team should have input into the process.A Discharge criteria for the PACU Discharge criteria must be defined for the PACU.e.mpaic. admission to a high-care area (i. Criteria should be primarily the responsibility of the  availability of trained recovery staff anaesthetist. 4th edn March 2007. London: Operating Department.e. The Associa- from the anaesthetist regarding consideration for referral tion of Anaesthetists of Great Britain and Ireland.aagbi. not obstructed.06.pdf. http://dx. handover documentation completed e either physically or diogram/respiratory rate) electronically  intravenous drip stands  temperature: over 36 C. well oxygenated FURTHER READING  circulation: stable cardio-pulmonary rate/rhythm within Allman KG. OUP acceptable limits. Standard discharge criteria include: 2 Health Building Note 26. Patient recovery and the post-anaesthesia care unit (PACU).int/ clear airway patientsafety/safesurgery/en/. and if a patient REFERENCES fails to meet these criteria then recovery staff should seek advice 1 Immediate post-anaesthetic recovery.  airway: able to cough (i. Anaesthesia and intensive care medicine (2015). www. September 2002. return of full airway reflexes). adequate depth. ANAESTHESIA AND INTENSIVE CARE MEDICINE --:. a 4 World Health Organization.