1. INTRODUCTION & PURPOSE
The immediate post-anesthesia period is a critical phase of recovery characterized by significant physiologic changes and risks, including airway compromise, respiratory depression, hemodynamic instability, and emergence delirium. The purpose of this policy is to establish standardized, evidence-based clinical practice guidelines for the management of patients in the Post-Anesthesia Care Unit (PACU) to ensure optimal safety, quality of care, and efficient recovery.
This policy mandates a systematic approach to post-anesthesia care consistent with the CBAHI National Standards for Perioperative Safety (POR), specifically addressing requirements for continuous monitoring during recovery (POR.6.3) and standardized discharge using defined evidence-based criteria (POR.6.4). It aligns with the American Society of Anesthesiologists (ASA) Standards for Postanesthesia Care (Amended October 23, 2024), which dictates that all patients who have received general anesthesia, regional anesthesia, or monitored anesthesia care shall receive appropriate postanesthesia management.
The primary objectives of these standards are to:
- Ensure every patient receives continuous, vigilant monitoring by qualified personnel during the recovery phase.
- Standardize the transfer of care (handover) process to reduce communication errors and loss of critical information.
- Define quantitative physiologic criteria for recovery progression and discharge readiness (Phase I to Phase II/Ward/ICU).
- Establish protocols for the prevention, early recognition, and management of common postoperative complications including pain, nausea/vomiting (PONV), hypothermia, and respiratory adverse events.
- Provide clear escalation pathways for clinical deterioration.
These standards apply to all Phase I recovery care provided in the main PACU and any Non-Operating Room Anesthesia (NORA) recovery areas designated as providing Phase I level care. Adherence to these guidelines is mandatory for all anesthesia professionals, PACU nursing staff, and perioperative team members involved in patient recovery.
2. SCOPE & APPLICABILITY
2.1 Patient Populations
This policy applies to all adult and pediatric patients recovering from:
- General Anesthesia (GA) with or without airway instrumentation.
- Regional/Neuraxial Anesthesia (Spinal, Epidural, Peripheral Nerve Blocks) with or without sedation.
- Monitored Anesthesia Care (MAC).
- Procedural Sedation managed by anesthesia services (Moderate/Deep Sedation).
2.2 Clinical Locations
This policy applies to:
- Main PACU (Phase I): The primary high-acuity recovery area.
- Phase II Recovery Area: Step-down unit for ambulatory surgery discharge preparation (where applicable).
- NORA Recovery Areas: Endoscopy, Interventional Radiology, Cath Lab, MRI, and other procedural suites providing post-anesthesia recovery.
- ICU/CCU: When a patient bypasses PACU for direct admission, PACU standards for handover and immediate recovery monitoring apply during the initial stabilization phase.
2.3 Personnel
This policy applies to Anesthesiologists, Anesthesia Technicians/Technologists, PACU Registered Nurses, Respiratory Therapists, and receiving unit nursing staff (Ward/ICU).
3. DEFINITIONS
- PACU Phase I: The immediate high-intensity level of care following anesthesia, focusing on airway protection, hemodynamic stabilization, pain control, and neurological recovery. Staffing ratio typically 1:2 (or 1:1 for unstable/unconscious patients).
- PACU Phase II: A lower-intensity level of care for patients who have met Phase I discharge criteria, focusing on preparation for discharge home (ambulatory surgery) or to an unmonitored ward. Staffing ratio typically 1:3-5.
- Aldrete Score (Modified): A standardized quantitative tool used to assess physiologic recovery and readiness for discharge from Phase I, evaluating activity, respiration, circulation, consciousness, and oxygen saturation.
- Structured Handover: A formalized process of transferring patient information and responsibility using a standardized framework (e.g., SBAR, I-PASS) to ensure completeness and accuracy.
- Opioid-Induced Ventilatory Impairment (OIVI): A spectrum of opioid side effects ranging from mild hypoventilation to severe respiratory depression and apnea, often preceding oxygen desaturation.
- Unplanned ICU Admission: Admission to an intensive care unit from the PACU for a patient originally scheduled for ward admission or discharge home, due to intraoperative or immediate postoperative complications.
- Postoperative Respiratory Complication (PRC): Any adverse respiratory event including aspiration, bronchospasm, laryngospasm, hypoventilation, hypoxia, or re-intubation.
4. REGULATORY & EVIDENCE FRAMEWORK
This policy is founded on international standards and evidence-based guidelines:
- CBAHI National Standards (POR): Mandates standardized recovery monitoring, documentation, and discharge criteria.
- ASA Standards for Postanesthesia Care (2024): Defines requirements for patient transport, handover, continuous monitoring (oxygenation, ventilation, circulation, temperature), and physician supervision.
- ASA Practice Guidelines for Postanesthetic Care (2013): Provides recommendations for monitoring, antagonism of neuromuscular blockade, and management of emergence.
- APSF & Joint Commission Guidelines: Emphasize standardized handoff communication (SBAR) to prevent medical errors.
- Fourth Consensus Guidelines for the Management of PONV (Gan et al., 2020): Protocols for risk assessment, prophylaxis, and rescue treatment.
- NICE Clinical Guideline [CG65] (2016): Hypothermia prevention and management in adults having surgery.
- Difficult Airway Society (DAS) Guidelines: Management of extubation and airway crises in recovery.
5. PACU ADMISSION & HANDOVER PROTOCOLS (D1)
5.1 Transport and Accompaniment Requirements
In accordance with ASA Standards, all patients shall be transported from the anesthetizing location to the PACU accompanied by a member of the anesthesia care team who is knowledgeable about the patient's condition. The anesthesia provider shall remain with the patient until vital signs have been measured, the patient is stable, and the transfer of care (handover) to the PACU nurse is completed.
- Monitoring During Transport: Continuous pulse oximetry and clinical observation of airway/ventilation are mandatory. Supplemental oxygen shall be provided for all patients who received general anesthesia or deep sedation.
- High-Risk Transport: For unstable patients, continuous ECG and hemodynamic monitoring shall be maintained during transport. Emergency airway equipment and drugs must be immediately available.
5.2 Immediate Arrival Assessment (First 3-5 Minutes)
Upon arrival in the PACU, the following actions must be performed immediately (concurrent with handover):
- Monitor Connection: Attach Pulse Oximeter, NIBP cuff, and ECG leads (if indicated). Initiate vital signs measurement immediately.
- Oxygen Therapy: Connect supplemental oxygen (nasal cannula, face mask, or high-flow system) as clinically indicated.
- ABCDE Assessment:
- Airway: Patency, secretions, artificial airway position (if present).
- Breathing: Rate, depth, effort, symmetry, SpO2.
- Circulation: Heart rate, rhythm, blood pressure, perfusion status.
- Disability: Level of consciousness (AVPU), pupil response.
- Exposure: Surgical site, dressings, drains, temperature.
- IV Access Verification: Confirm patency of IV lines and verify running infusions.
5.3 Structured Handover Protocol (Evidence-Based SBAR)
A standardized verbal handover using the SBAR (Situation-Background-Assessment-Recommendation) framework is mandatory to ensure complete information transfer. The PACU nurse should focus exclusively on the handover during this time.
MINIMUM REQUIRED HANDOVER CONTENT (15 Elements):
1. Patient & Procedure (Situation): Name, Age, MRN, Procedure performed, Surgeon.
2. Anesthetic Technique (Background): Type (GA/MAC/Regional), Airway device (ETT/LMA size), Difficult airway details (grade, adjuncts used).
3. Intraoperative Events (Background): Hemodynamic instability, respiratory events, arrhythmias, allergic reactions, complications.
4. Current Status (Assessment): Most recent BP/HR/SpO2, ventilatory status, residual sedation.
5. Analgesia Plan (Assessment): Regional blocks (type/level), Opioids given (total dose/time of last dose), Non-opioids given, PCA plan, Pain score.
6. PONV Risk (Assessment): Risk level, Prophylaxis given, Rescue plan.
7. Neuromuscular Blockade (Assessment): Agent used, Reversal given (Neostigmine vs Sugammadex), Adequacy (TOF ratio).
8. Fluids & Hemodynamics (Assessment): Total fluids given, EBL, Urine output, Vasopressor infusions.
9. Antibiotics (Background): Dose/time given, Redosing requirements.
10. Temperature (Assessment): Current temp, Active warming status.
11. Surgical Concerns (Assessment): Drains/Dressings, Specific positioning/immobilization instructions.
12. Destination/Plan (Recommendation): Phase I discharge criteria, Ward vs ICU, Special monitoring needs (OSA/Bleeding).
13. Allergies (Background): Drug/Latex allergies.
14. Family (Situation): Notification status.
15. Questions (Interactive): Opportunity for PACU nurse to clarify information.
5.4 PACU Nurse Acceptance
Responsibility for patient care is transferred to the PACU nurse only after:
- Vital signs are stable and within acceptable limits.
- Airway is patent and breathing is adequate.
- Handover is complete and questions answered.
- Anesthesia provider documentation is complete.
6. PACU MONITORING STANDARDS & FREQUENCY (D2)
6.1 Regulatory Basis
The ASA Standards for Postanesthesia Care mandate that "A patient recovering from anesthesia shall be monitored and vital signs shall be recorded frequently as deemed appropriate by the anesthesiologist." Monitoring must be continuous and documented at intervals sufficient to detect deterioration early.
6.2 Minimum Monitoring Elements (ASA-Aligned)
A. Oxygenation Monitoring:
- Continuous Pulse Oximetry (SpO2): MANDATORY for all patients in Phase I recovery.
- Alarms: Audible alarms must be active (typically set low limit 90-92%).
- Clinical Assessment: Skin color and perfusion must be assessed regularly, recognizing limitations of pulse oximetry (lag time, motion artifact, poor perfusion).
B. Ventilation Monitoring:
- Clinical Assessment: Respiratory rate, depth, pattern, and work of breathing must be assessed continuously.
- Capnography (ETCO2): Strongly recommended for high-risk patients (OSA, obesity, heavy opioid use) and mandatory for patients with artificial airways or deep sedation. It provides the earliest warning of airway obstruction or hypoventilation.
- Respiratory Rate Target: 10-20 breaths/min (adult). Bradypnea (<8-10) or Tachypnea (>25) requires immediate evaluation.
C. Circulation Monitoring:
- Electrocardiogram (ECG): Continuous ECG monitoring is required for Phase I recovery to detect arrhythmias and ischemia.
- Blood Pressure (NIBP):
- Frequency: Measured immediately on arrival, then at least every 5 minutes for the first 15 minutes, and every 15 minutes thereafter if stable.
- Unstable Patients: Frequency increased to every 5 minutes or continuous invasive arterial monitoring as indicated.
- Heart Rate: Continuous monitoring via ECG and Pulse Oximetry.
- Perfusion Assessment: Capillary refill time, skin temperature, and urine output (if catheterized).
D. Temperature Monitoring:
- Measurement: Core temperature (tympanic/oral) must be measured on admission and prior to discharge.
- Hypothermia Protocol: If admission temperature <36.0°C, continuous warming measures are applied, and temperature is monitored every 15-30 minutes until normothermia is achieved.
E. Neurological Monitoring:
- Level of Consciousness: Assessed on admission and with each set of vital signs using standardized scales (e.g., AVPU, RASS).
- Motor Function: Assessment of neuromuscular recovery (grip strength, head lift) and regression of regional blockade (Bromage score).
6.3 Monitoring Frequency Summary Table
| Parameter |
Admission |
First 15 Minutes |
Subsequent (Stable) |
High Risk / Unstable |
| SpO2 |
Continuous |
Continuous |
Continuous |
Continuous |
| ECG / Heart Rate |
Continuous |
Continuous |
Continuous |
Continuous |
| Blood Pressure |
Immediate |
Every 5 min |
Every 15 min |
Every 5 min |
| Respiratory Rate |
Immediate |
Every 5 min |
Every 15 min |
Continuous (Capnography) |
| Temperature |
Immediate |
As indicated |
Every 30 min if abnormal |
Continuous (if invasive) |
| Pain / PONV Score |
Immediate |
Every 15 min |
Every 15-30 min |
After interventions |
| Sedation Score |
Immediate |
Every 15 min |
Every 30 min |
Every 15 min |
6.4 Continuous Observation Requirement
PACU nursing staff must provide continuous visual observation of patients. Staffing ratios should be adjusted based on acuity:
- 1:2 Ratio: Standard Phase I recovery (stable, unconscious/conscious).
- 1:1 Ratio: Unstable airway, hemodynamic instability, age < 8 years (until stable), or upon admission (first 15 min).
- 2:1 Ratio: Critically ill, unstable, complex isolation.
7. POST-ANESTHESIA RECOVERY SCORING SYSTEMS (D3)
7.1 Purpose of Recovery Scoring
Quantitative scoring systems provide an objective, evidence-based method to assess physiologic recovery and determine readiness for discharge. The Modified Aldrete Score is the standard for Phase I recovery.
7.2 Modified Aldrete Score (PAR Score)
The score evaluates 5 domains. A total score of ≥9 out of 10 is generally required for discharge (exceptions require physician documentation).
| DOMAIN |
CRITERIA |
SCORE |
1. ACTIVITY
(Motor Function) |
Able to move 4 extremities voluntarily or on command |
2 |
| Able to move 2 extremities voluntarily or on command |
1 |
| Unable to move extremities |
0 |
| 2. RESPIRATION |
Able to breathe deeply and cough freely |
2 |
| Dyspnea, shallow or limited breathing |
1 |
| Apnea |
0 |
3. CIRCULATION
(Blood Pressure) |
BP ± 20 mmHg of pre-anesthetic level |
2 |
| BP ± 20-50 mmHg of pre-anesthetic level |
1 |
| BP ± 50 mmHg or more of pre-anesthetic level |
0 |
| 4. CONSCIOUSNESS |
Fully awake |
2 |
| Arousable on calling |
1 |
| Not responding |
0 |
5. OXYGEN SATURATION
(Pulse Oximetry) |
SpO2 > 92% on room air |
2 |
| Needs O2 to maintain SpO2 > 90% |
1 |
| SpO2 < 90% even with O2 supplement |
0 |
7.3 Scoring Interpretation & Action
- Score 9-10: Ready for Phase I Discharge (if other criteria met).
- Score 7-8: Requires continued Phase I monitoring. Optimize oxygenation, analgesia, and fluids.
- Score <7: Significant physiologic instability. Requires immediate evaluation by anesthesia provider and potential escalation of care.
7.4 Documentation Requirements
The Modified Aldrete Score must be documented:
- On PACU Admission (Baseline).
- Every 15-30 minutes during recovery.
- At the time of Discharge decision (Final Score).
7.5 Alternative Scores
- PADSS (Post-Anesthetic Discharge Scoring System): Used for Phase II discharge (Ambulatory Surgery).
- Steward Score: Simplified score for pediatric patients (Consciousness, Airway, Movement).
- Bromage Score: Specifically for assessing motor block regression in regional anesthesia.
8. PACU DISCHARGE CRITERIA (D4)
8.1 General Discharge Principles
Discharge from PACU Phase I to a ward, ICU, or Phase II unit occurs only when the patient meets defined physiologic safety criteria. The decision is a collaborative process led by the anesthesia provider and PACU nursing staff.
8.2 Phase I Discharge Criteria (Standard Ward Transfer)
Patients are eligible for discharge to a general inpatient ward when they meet the following evidence-based thresholds:
- Physiologic Stability (Aldrete Score ≥9):
- Return to baseline mental status (or appropriate for age/condition).
- Stable vital signs for at least 30 minutes.
- SpO2 >92% on Room Air (or baseline oxygen requirement).
- Respiratory Safety:
- Patent airway with adequate protective reflexes (swallow/cough).
- No signs of respiratory distress, stridor, or significant work of breathing.
- Respiratory rate 10-20/min (adult).
- Hemodynamic Stability:
- No active bleeding.
- No requirement for vasoactive infusions (unless transferring to ICU/Step-down).
- Urine output adequate (>0.5 mL/kg/hr) if catheterized.
- Symptom Control:
- Pain: Controlled to tolerable level (typically <4/10) with oral/IV medication regimen established for ward.
- PONV: Nausea controlled; no active vomiting for at least 30 minutes.
- Temperature: Normothermic (>36.0°C) without active shivering.
- Surgical Site:
- Dressings dry/intact; no expansion of hematoma.
- Drains functioning properly.
- Regional Anesthesia:
- Sensory level regressing; no signs of high spinal/epidural.
- Hemodynamic stability confirmed post-block.
8.3 Discharge to Intensive Care Unit (ICU)
Patients who do NOT meet Phase I criteria due to critical illness or high monitoring needs must be transferred to an ICU. Criteria for direct ICU transfer include:
- Requirement for mechanical ventilation or advanced airway support.
- Hemodynamic instability requiring vasoactive infusions (pressors/inotropes).
- Invasive monitoring requirement (Arterial line, CVP, PICCO).
- Severe coagulopathy or active hemorrhage.
- Post-cardiac arrest or severe intraoperative complications.
- Failure to awaken (delayed emergence) requiring neurological monitoring.
8.4 Discharge to Phase II (Ambulatory Surgery)
For patients proceeding to discharge home, Phase II criteria apply (PADSS Score ≥9). Additional requirements include:
- Ability to ambulate (if appropriate).
- Ability to tolerate oral fluids (if required by protocol).
- Voiding (for specific procedures like spinal anesthesia, pelvic surgery).
- Responsible adult escort present.
8.5 Physician Authorization
Discharge must be authorized by an anesthesia provider. This may be:
- Direct Authorization: Physician assesses patient and writes discharge order.
- Protocol-Based Authorization: Nurse may discharge if strict criteria are met, documented, and standing orders allow (as per hospital policy).
9. PAIN MANAGEMENT PROTOCOLS (D5)
9.1 Assessment Standards
Pain management in the PACU is a priority. Assessment must be frequent, documented, and multidimensional.
- Frequency: On admission, every 15 minutes, and within 15-30 minutes after any analgesic intervention (Reassessment).
- Tools:
- Numeric Rating Scale (NRS 0-10) for adults/older children.
- FLACC Scale for pediatric/non-verbal patients.
- Critical Care Pain Observation Tool (CPOT) for intubated patients.
- Target: Pain Score < 4/10 or patient-reported "tolerable" level.
9.2 Multimodal Treatment Approach
A multimodal approach reduces opioid consumption and side effects (OIVI, PONV).
Step 1: Non-Opioid Foundation (Unless Contraindicated)
- Acetaminophen IV (1g) if not given intraop.
- NSAIDs (Ketorolac 15-30mg IV) for appropriate candidates (check renal function/bleeding risk).
- Regional Anesthesia: Verify block function; considering rescue block for severe pain.
Step 2: Opioid Titration (Moderate-Severe Pain)
- Fentanyl: 25-50 mcg IV increments q5-10min. Rapid onset, short duration.
- Morphine: 2-4 mg IV increments q10-15min. Longer onset/duration.
- Hydromorphone: 0.2-0.5 mg IV increments q10-15min. Potent, use with caution.
Step 3: Rescue / Adjuvants
- Ketamine: Low dose (0.1-0.2 mg/kg) for opioid-refractory pain.
- Lidocaine Infusion: Consider for visceral pain.
- Dexmedetomidine: For pain with agitation/anxiety.
9.3 Opioid-Induced Ventilatory Impairment (OIVI) Monitoring
Patients receiving IV opioids are at risk for OIVI. Monitoring is critical:
- Risk Factors: OSA, Obesity, Elderly, Opioid Naïve, Renal Failure, CNS depressants.
- Monitoring: Continuous SpO2 and Respiratory Rate. Capnography is recommended for high-risk patients receiving opioids.
- Sedation Assessment: Use Pasero Opioid-Induced Sedation Scale (POSS).
- POSS 3 (Frequently drowsy/drifts off): Decrease opioid dose.
- POSS 4 (Somnolent/minimal response): STOP opioid, consider Naloxone, stimulate patient.
9.4 Naloxone Protocol (Opioid Reversal)
Indicated for severe respiratory depression (RR <8, SpO2 <90%, POSS 4).
- Dosing: Dilute 0.4mg ampoule in 9mL NS (total 10mL). Administer 0.04mg (1mL) increments IV every 2-3 minutes until respiratory rate improves.
- Goal: Restore adequate ventilation without reversing analgesia completely.
- Observation: Monitor for at least 60-90 minutes post-naloxone for "renarcotization" (opioid duration > naloxone duration).
10. PONV MANAGEMENT PROTOCOLS (D6)
10.1 Evidence-Based Guidelines (Fourth Consensus Guidelines 2020)
Postoperative Nausea and Vomiting (PONV) affects 30% of surgical patients and can delay discharge and increase morbidity.
10.2 Assessment & Risk Stratification
- Apfel Score (Adults): Female, Non-smoker, History of PONV/Motion Sickness, Postop Opioids. (0-4 risk factors = 10-80% risk).
- Assessment Frequency: On admission and with vital signs. Patient self-report ("Are you nauseous?").
10.3 Rescue Treatment Algorithm
Treatment is guided by what prophylaxis was given intraoperatively. Do not repeat agents given within the last 6 hours (except short-acting). Use a different class of antiemetic.
First-Line Rescue (If not given recently):
- Ondansetron (5HT3 Antagonist): 4mg IV (may repeat once).
Second-Line Rescue (If Ondansetron fails or was given intraop):
- Dexamethasone (Steroid): 4-8mg IV (slow push). *Caution in labile diabetes/awake patients (perineal burning).
- Droperidol or Haloperidol (Butyrophenones): 0.625-1.25mg IV. *Monitor QT interval.
- Promethazine (Phenothiazine): 6.25-12.5mg IV. *Sedating, risk of extravasation injury.
Third-Line / Adjuvants:
- Metoclopramide: 10mg IV. (Prokinetic, weak antiemetic).
- Scopolamine Patch: Apply early if not done.
- Isopropyl Alcohol Swabs: Aromatherapy (evidence supports temporary relief).
- Hydration: Ensure adequate IV fluid resuscitation (20mL/kg).
11. RESPIRATORY EVENT ESCALATION (D7)
11.1 Airway Emergencies in PACU
Respiratory complications are the most common cause of PACU morbidity. Immediate recognition and intervention are critical.
11.2 Management Algorithms
A. Airway Obstruction / Stridor:
- Signs: Snoring, paradoxical chest movement, desaturation, stridor.
- Immediate Action: Jaw thrust/Chin lift, Oral/Nasal Airway insertion, 100% Oxygen.
- Treatment: Suction secretions. If stridor (laryngeal edema): Racemic Epinephrine nebulizer, Dexamethasone 4-8mg IV.
- Escalation: Call Anesthesia. Prepare for re-intubation if impending failure.
B. Laryngospasm:
- Signs: High-pitched crowing or silence (complete spasm), rapid desaturation, bradycardia (late).
- Action:
- Remove Stimulus: Stop suctioning/movement.
- Positive Pressure: CPAP with 100% Oxygen (Tight mask seal + 20-30 cmH2O pressure).
- Larson's Maneuver: Jaw thrust + pressure on laryngospasm notch.
- Pharmacologic (If hypoxia persists): Propofol (sub-hypnotic dose 0.5mg/kg) or Succinylcholine (0.1-0.5 mg/kg IV).
- Re-intubation: If spasm unresolved.
C. Hypoventilation / Apnea:
- Causes: Opioids, Residual Neuromuscular Blockade, Sedatives.
- Assessment: Check RR, ETCO2 (high), TOF ratio.
- Intervention:
- Stimulate Patient: Verbal/Tactile.
- Reverse Opioids: Naloxone (titrated).
- Reverse Benzodiazepines: Flumazenil (0.2mg IV). *Seizure risk.
- Reverse NMB: Neostigmine or Sugammadex (if TOF ratio <0.9).
D. Hypoxemia (SpO2 <90%):
- Algorithm:
- Increase FiO2 (Non-rebreather mask).
- Assess Airway/Breathing (Auscultate).
- Check for: Atelectasis, Pneumothorax, Pulmonary Edema, Pulmonary Embolism.
- Intervention: Upright positioning, Recruitment maneuvers, Diuretics (if fluid overload), Bronchodilators (if wheezing).
- Diagnostic: CXR, ABG.
11.3 Re-Intubation Protocol
Re-intubation is a high-risk event associated with increased mortality. It must be performed by an experienced anesthesia provider.
- Triggers: Inability to maintain airway, persistent hypoxemia (SpO2 <88% on high FiO2), severe respiratory acidosis (pH <7.20), GCS <8.
- Procedure: Call for help/code cart. Pre-oxygenate. Rapid Sequence Induction (RSI) usually indicated.
- Disposition: All re-intubated patients must be transferred to ICU.
12. HYPOTHERMIA & SHIVERING MANAGEMENT (D8)
12.1 Regulatory Basis (NICE CG65)
Inadvertent perioperative hypothermia (Core Temp <36.0°C) is associated with surgical site infections, coagulopathy, prolonged drug effects, and morbid cardiac events. Prevention and treatment are mandatory.
12.2 Temperature Assessment
- Core temperature measurement on admission is mandatory.
- Preferred sites: Tympanic, Temporal (if validated), Bladder (if catheterized).
- Hypothermia Definition: Core temperature < 36.0°C.
12.3 Warming Protocol
For Hypothermic Patients (<36.0°C):
- Active Forced-Air Warming (Bair Hugger): First-line treatment. Apply immediately.
- Warmed IV Fluids: Use fluid warmers for any bolus fluids/blood products.
- Passive Warming: Warm cotton blankets (less effective alone but useful adjunct).
- Monitoring: Recheck temperature every 15-30 minutes.
- Goal: Minimum 36.0°C prior to discharge.
12.4 Post-Anesthetic Shivering (PAS)
Shivering increases oxygen consumption by 200-500% and aggravates pain.
- Causes: Hypothermia, Volatile anesthetics, Pain, Pyrogen release.
- Treatment:
- Warm Patient: Forced-air warming (skin surface warming treats shivering best).
- Pharmacologic: Meperidine (Pethidine) 12.5-25mg IV (Most effective agent; acts on kappa receptors). *Avoid in MAOI/SSRI users.
- Alternative: Clonidine 30-75mcg IV, Dexmedetomidine, or Magnesium Sulfate.
13. TRANSFER & HANDOVER TO WARD/ICU (D9)
13.1 Discharge Decision
Once discharge criteria (Section 8) are met, the anesthesia provider or authorized nurse initiates discharge.
13.2 Structured Ward Handover
A verbal report to the receiving ward nurse is mandatory (phone or in-person). It must follow the SBAR format and include:
- Situation: Patient Name, Procedure, Transferring from PACU.
- Background: Anesthesia type, Allergies, Comorbidities.
- Assessment:
- Vital signs range in PACU.
- Pain status (Last dose, Plan).
- PONV status.
- Surgical site/drains status.
- Fluid balance / Output.
- Recommendation:
- Specific monitoring orders (e.g., O2 therapy, Pulse Ox).
- IV fluid orders.
- Next antibiotic dose.
- Call criteria for physician.
13.3 Transport to Ward
- Patient transported by porter and nurse (if indicated).
- Oxygen via cylinder if SpO2 labile.
- Handover of paperwork/records.
14. SPECIAL POPULATIONS
14.1 Pediatrics
- Emergence Delirium: Common (10-30%). Assess with PAED scale. Treat with reassurance, parent presence, Fentanyl/Propofol/Dexmedetomidine if severe.
- Airway: Higher risk of laryngospasm/croup. "No touch" emergence often used.
- Dosage: All medications weight-based. Double-check required.
- Family: Parent presence in PACU encouraged as soon as feasible.
14.2 Obstructive Sleep Apnea (OSA)
- High Risk: Airway obstruction, opioid sensitivity.
- Monitoring: Continuous SpO2 + Capnography recommended.
- Positioning: Head elevated 30-45° or lateral.
- CPAP: Patient's home CPAP should be applied in PACU if desaturating or obstructing.
14.3 Regional Anesthesia
- Motor/Sensory Check: Document regression of block.
- Safety: Protect insensate limbs. Fall precautions.
- Spinal: Confirm regression (e.g., < T10) and hemodynamic stability before discharge.
15. RESPONSIBILITIES
Anesthesiologist / Anesthesia Provider:
- Safe transport and structured handover to PACU.
- Ordering PACU medications, fluids, and discharge criteria.
- Available for immediate consultation/intervention for complications.
- Authorizing discharge (or delegating via protocol).
PACU Registered Nurse:
- Continuous monitoring and assessment per policy.
- Administering medications and treatments.
- Recognizing deterioration and escalating care.
- Documentation of care and discharge scoring.
PACU Charge Nurse:
- Managing patient flow and staffing.
- Ensuring resources for high-acuity patients.
17. QUALITY ASSURANCE & AUDIT
Compliance with this policy will be monitored through regular audits. Key Performance Indicators (KPIs) include:
| Indicator |
Target |
Method |
| Handover Compliance |
100% |
Random audit of SBAR usage |
| Monitoring Frequency |
>95% |
Chart audit (Vitals q15min) |
| Pain Management |
>90% |
Patients with Pain <4 at discharge |
| Hypothermia Rate |
<5% |
Temp <36.0°C at discharge |
| Unplanned ICU Admission |
<2% |
Incident reporting |
| Re-intubation Rate |
<1% |
Incident reporting |