Dpp-An-004 (2) Anesthetic Post-Operative Care Recovery Room

Kingdom of Saudi Arabia ‫المملكة العربية السعودي‬
Ministry of Health ‫وزارة الصحة‬

Directorate of Health Affairs - Najran ‫مديرية الشؤون الصحية – نجران‬
Khobash General Hospital ‫مستشفى خباش العام‬
Department: ANESTHESIA DEPARTMENT Original Date: 20.07.2018

Policy Code Number: DPP-AN-004 Revision Date: 28.06.2020
Version Number: 2 Effective Date: 28.07.2020
Title: ANESTHETIC POST-OPERATIVE CARE Review Due: 28.06.2022
RECOVERY ROOM
1. STATEMENT OF PURPOSE
1.1 Regulation of post anesthetic period in an optimum & safe manner in order to avoid any
expected or unexpected complication.
1.2 The primary goal of the Post Anesthesia Care Unit (PACU) is to provide a safe
environment (with presence of skilled nurses, appropriate monitoring, and resuscitative
equipments), where patients can return to their pre-anesthetic homeostasis.
1.3 Most PACU incidents leading to serious morbidity are related to inadequate monitoring.
2. APPLICABILITY
2.1. All staff in the Anesthesia
3. DEFINITIONS
3.1 Recovery room (Post Anesthetic Care Unit PACU). It is well equipped room for reception
the patient postoperatively for continuous monitoring till is charged according to criteria
of discharge. It’s design facilitating observation of all patients simultaneously.
3.2 The modified Aldrete’s scoring system is commonly used for determining when patients
can be safely discharged from the PACU to either the postsurgical ward for in- patients or
to the home for out -patients.
4. POLICIES
4.1 Following anesthesia and surgery, peri-operative monitoring should be continued in the
PACU for all patients who are likely to require a period of physiological stabilization.
4.2 At the end of surgery and anesthesia, each patient’s physiological status is continuously
monitored prior to shifting the patient from OR to PACU and this is to be fully
documented in post anesthesia evaluation space in anesthetic record.
- Vital signs (Blood pressure- Pulse rate & rhythm- Respiratory Rate-Temperature-
Pain) & ECG
- Airway clearance.
- O2 saturation on air.
- Protective reflexes e.g.: cough, swallowing, eye opening.
- Level of consciousness (Response to verbal comments).
4.3 Patient is accompanied by the anesthesia technician and anesthesia provider to Post
DPP-AN-004 (2) Page 1 of 10


RECOVERY ROOM
Anesthesia Care Unit to be supervised by Post Anesthesia Care Unit Staff where the
patient is fully monitored and documented in Post Anesthesia Recovery Evaluation Form.
4.4 A qualified anesthetist is in charge of the Recovery room at all times
4.5 An appropriate standard of monitoring should be maintained until patients have recovered
from anesthesia and good records made to support effective ‘handover’ to ward staff
4.6 Requirements for critical care after surgery should be assessed and facilities made
available for all patients deemed to need these
4.7 Some patients may require to be transferred to surgical ICU for continuous monitoring
(eg: major operations or critical cases).
4.8 Following minimum of 30-60 min, patient can be transferred to his/her room if he/she is
fulfilling the following criteria (modified Aldertte score ) and pain scale:
4.9 Discharging criteria
4.9.1 Full consciousness.
4.9.2 Regained reflexes (cough, swallowing)
4.9.3 Elevated head unsupported for 5 seconds (muscle tone)
4.9.4 Arterial Blood Pressure and heart rate (stable)
4.9.5 Respiration is spontaneous, regular, not obstructed
4.9.6 Color is normal (not pale or cyanosed)
4.9.7 O2 saturation on air is normal
4.9.8 Minimal/No pain
4.10 In Post Anesthesia Care Unit, only a qualified anesthetist discharges the patient from the
Recovery room and will sign over these criteria on the Post Anesthesia Recovery
Evaluation Form.
4.11 The recovery room has a method to call for help quickly through an alarm system or
paging system without leaving the patient’s bedside
5. RESPONSIBILITY
5.1. Anesthetist (resident)

5.2. Anesthesia provider
5.3. Recovery room nurse.
6. PROCEDURES
6.1. The Recovery Room nurse receives a report about the patient’s condition from the
anesthesia provider. The report provides a description of pertinent medical and surgical
history, the condition requiring surgery, the surgical procedure and any complications, the
anesthesia, medications given during surgery, any difficulties with intubation, and the


RECOVERY ROOM
estimated blood loss from surgery, fluid status of the patient, transfusions, and vital signs.
6.2. The patient should be physiologically stable on departure from the operating theatre and
the anesthetist must decide on the need for monitoring during transfer. The anesthetist is
responsible for ensuring that this transfer is accomplished safely. Supplemental oxygen
should be administered to all patients during transfer.
6.3. A complete system assessment of the patient is conducted immediately on arrival to the
PACU. The nurse uses the ABCs (i.e., airway–breathing–circulation) to prioritize the
initial assessment of the surgical patient starting with observation of the airway for
patency.
6.4. Unless contraindicated, recovering patients are placed in a lateral position to reduce the
risk of aspiration. An artificial airway (oral or nasal) prevents the tongue from falling
backward and occluding the airway. It may be used until the patient is able to support her
airway unassisted.
6.5. Humidified oxygen is placed via face mask and titrated to keep oxygenation saturation
levels above 93% or at a level determined by the health care provider. For the first 2 hours
after surgery, the patient may be placed on high levels of oxygen (e.g., FIO 2 greater than
80%) because evidence suggests that this will destroy pathogens and reduce the risk of
surgical-site infections
6.6. The nurse assesses the patient’s respiratory rate and depth, breath sounds, and oxygen
saturation via a continuous pulse oximeter.
6.7. The nurse performs the respiratory assessments described above and, in addition, checks
the endotracheal tube and ventilator settings. A cardiac monitor is attached to the patient as
well as a blood pressure cuff. Apical pulse and blood pressure are taken and the patient’s
heart rhythm is noted.
6.8. The nurse assesses peripheral pulses and the patient’s color as indices of the adequacy of
circulation.
6.9. The patient’s core body temperature is measured using the monitoring device considered
best according to agency policy and the nurse’s judgment. Temperature can fluctuate
rapidly during recovery.
6.10. The PACU nurse performs a systematic, head-to-toe assessment of the patient and
documents her findings in the patient’s medical records. The following areas are assessed
during the head-to-toe examination
6.10.1. level of consciousness
6.10.2. Hemoglobin oxygen saturation and oxygen administration
6.10.3. Blood pressure
6.10.4. Respiratory frequency
6.10.5. Heart rate and rhythm
6.10.6. Pain intensity e.g. verbal rating scale (none, mild, moderate, severe)
6.10.7. Intravenous infusions
6.10.8. Drugs administered


RECOVERY ROOM
6.10.9. Other parameters (depending on circumstances) e.g. temperature, urinary output,

central venous pressure, end-tidal CO2, surgical drainage.
6.11. Pain and Emesis
6.11.1 No patient should be returned to the general ward until control of emesis and
postoperative pain is satisfactory
6.12. Tracheal tubes and other airway devices
6.12.1 Most of the time, patients will be handed over to the recovery nurse with a
laryngeal mask airway in situ.
6.12.2 The removal of tracheal tubes from patients in the recovery room is the
responsibility of an anesthetist.
6.13. Abnormal assessments that are reported to the anesthesiologist
6.13.1 NEUROLOGICAL FINDINGS
6.13.1.1 Prolonged unresponsiveness
6.13.1.2 Change in level of consciousness
6.13.1.3 Abnormal responses such as slurred speech, asymmetrical smile,
weak hand grasps, inability to move all extremities
6.13.2 CARDIOVASCULAR FINDINGS
6.13.2.1 Heart rate >120 beats/min
6.13.2.2 Hypotension (e.g., systolic blood pressure of less than 90 mmHg)
6.13.2.3 New cardiac dysrhythmia
6.13.2.4 Hypertension (e.g., systolic blood pressure 20% to 30% higher than
baseline)
6.13.2.5 Absence of peripheral pulses
6.13.3 RESPIRATORY FINDINGS
6.13.3.1 Oxygen saturation < 93%
6.13.3.2 Respiratory rate <10 breaths/min
6.13.3.3 Indications of respiratory distress and/or hypoventilation such as
stridor, retraction of intercostal muscles, minimal respiratory effort
6.13.4 OTHER FINDINGS
6.13.4.1 Urine output < 30 mL hour or < 5 mL/kg per hour
6.13.4.2 More than the expected amount of bleeding at the incision site
6.13.4.3 Enlarging hematoma
6.13.4.4 Loss of pulse(s) in a graft site
6.13.4.5 Unexpected presence of blood in drainage tubes
6.13.4.6 More than the expected amount of drainage from chest tubes or wound
drains
6.13.4.7 Vomiting associated with possible aspiration
6.14 PACU DESIGN:
6.14.1 The PACU should be located near the operating rooms. It ensures that the patient
can be rushed back to surgery, if required or that members of the operating room


RECOVERY ROOM
staff can quickly attend to patients. Proximity to radiographic, laboratory, other

intensive care facilities on the same floor is also highly desirable.
6.14.2 At least one bed in closed patient space (RR isolated room) is desirable for
patients needing isolation for infection control.
6.14.3 Recovery room should be well lighted and large enough to allow easy access to
patients in spite of poles for intravenous infusion pumps, a ventilator or
radiographic equipment.
6.15 PACU EQUIPMENT:
6.15.1 Oxygen supply
6.15.2 Pulse oximetry (SpO2)
6.15.3 Automated blood pressure monitors
6.15.4 ECG machine.
6.15.5 All three monitors should be used for every patient in the initial phase of recovery
from anesthesia (Phase I care). Lesser monitoring may be appropriate
subsequently.
6.15.6 Guidelines requiring one set of monitors for every bed in order to avoiding more
serious PACU accidents.
6.15.7 Wall suction or suction equipment.
6.15.8 Capnography may be useful for intubated patients.
6.15.9 Temperature sensitive strips may be used to measure temperature in the PACU,
but are generally not sufficiently accurate to follow hypothermia or hyperthermia;
electronic thermometers should be used if an abnormality in temperature is
suspected.
6.15.10 A forced-air warming device, heating lamps, and warming/cooling blanket
should be available.
6.15.11 PACU should have its own supplies of basic and emergency equipment, separate
from that of the operating room. This includes oxygen, cannula, a selection of
masks, oral and nasal airways, and self – inflating Ambu bags for ventilation.
6.15.12 A defibrillator and an emergency crash cart with drugs and supplies for advanced
life support and infusion pumps should be present and periodically inspected
6.15.13 Tracheostomy, chest tube and vascular cut down trays are also mandatory.
6.15.14 Respiratory therapy equipment for aerosol bronchodilator treatments.
6.16 PACU STAFFING:

6.16.1 The PACU should be staffed by qualified anesthetist (resident) and nurse
specifically trained in the care of patients emerging from anesthesia.
6.16.2 All Recovery Room staff(medical and nursing) is certified in BCLS and
preferably ACLS
6.16.3 They should have expertise in airway management and cardiac life support as
well as problems commonly encountered in surgical patients relating to wound


RECOVERY ROOM
care, drainage catheters, and postoperative bleeding.

6.16.4 The management of the patient in the PACU should not differ from that in the
operating room and should reflect a coordinated effort between the
anesthesiologist, surgeon and any consultants.
6.16.5 The anesthesiologist still manages the analgesia as well as airway, cardiac,
pulmonary, and metabolic problems, whereas the surgeon manages any problems
directly related to the surgical procedure itself.
6.16.6 Based on the assumptions that the average PACU stay is 30-60 min and the
average procedure lasts 2 hours, a ratio of one recovery nurse for two patients is
generally satisfactory.
6.16.7 Staffing for nursing care should be tailored for each facility's unique
requirements.
6.16.8 A minimum of two nurses generally ensures that if one patient requires
continuous 1:1 nursing care, other patients will still be cared for adequately.
6.16.9 When the operating room schedule regularly includes pediatric patients or
frequent short procedures, a ratio of one nurse to one patient is often needed. A
charge nurse should be assigned to ensure optimal staffing at all times.
6.16.10 All personnel shall be familiar with and comply with hospital infection control
policies
6.16.11 All personnel entering the restricted areas of the OR suite will be properly attired
in accordance with OR policy.
6.17 IN-SERVICE EDUCATION:
6.17.1 All personnel in the PACU will participate in in-service education and training to
maintain or advance his or her skills and knowledge:
6.17.1.1 Observing and recognizing any arrhythmias
6.17.1.2 Reading from the Oximetry
6.17.1.3 Administering blood and blood products
6.17.1.4 BLS & ACLS certification
6.17.1.5 Infection control practices
6.17.1.6 The dosage and use of narcotics
6.17.1.7 Recognition of critical findings from physical assessment, assessments
from monitoring equipment, or diagnostic tests and the appropriate
interventions
6.17.1.8 The maintenance and preparedness of emergency equipment and drug
supply
6.17.2 Procedures concerning infection control are covered in staff orientation.
6.18 PACU SUPPLIES/EQUIPMENT:
6.18.1 Clean/sterile supplies will be stored appropriately in designated spaces.
6.18.2 Storage area must be clean, dry, and dust free. Supplies should be stored 8-10
inches from the floor, and 18-20 inches from the ceiling. Never store supplies in


RECOVERY ROOM
boxes on the floor.

6.18.3 All reusable equipment will be properly cleaned with an approved disinfectant and
sterilized, if indicated, after each use
6.18.4 Sterile items are checked daily. Items are rotated and sent back to CSSD when
indicated, for sterilization
6.18.5 Any instrument or equipment that enters the vascular system is a critical device,
and must be sterile
6.18.6 Disposable equipment will be used as much as possible
6.18.7 Ambu bags are for one time use only. When used, replace bag, and return to
CSSD for decontamination and sterilization
6.18.8 Equipment that touches the mucous membranes as Laryngoscopes and blades will
be thoroughly washed and scrubbed with a detergent immediately after each
patient use. The will then be immersed for 20 minutes in a Cidex solution and
thoroughly rinsed with sterile water before reuse
6.18.9 Stethoscopes and BP cuffs will be wiped down with an approved disinfectant
daily and if visibly soiled. If BP cuffs come in contact with body fluids, they are
to be washed in hot, soapy water before being cleaned with the disinfectant.
6.18.10 Disposable items and supplies will be disposed of in accordance with hospital
regulated medical waste policy. Infectious waste stands will be conveniently
located for disposal of waste.
6.18.11 Needles, syringes, and sharps will be disposed of in accordance with hospital
policy. Needles will not be recapped, bent, or cut. Sharps containers will be
conveniently located
6.18.12 Suction tips as well as suction tubing are changed after each patient. Suction
collection canisters will be changed as needed or every 24 hours.
6.18.13 Any tubing or masks having direct patient contact will be changed between each
patient.
6.18.14 All monitor cables will be cleaned daily with an approved disinfectant.
6.19 HANDLING OF INFECTIOUS CASES IN THE RECOVERY ROOM:
6.19.1 All patients are on “Universal/Standard Precautions” regardless of their diagnosis.
All blood/body fluids, secretions, wound drainage, etc., are considered potentially
infectious. Stringent aseptic technique will be practiced to reduce the
dissemination of microorganisms
6.19.2 At least one bed in closed patient space (RR isolated room) is desirable for
patients needing isolation for infection control
6.19.3 Isolation will be practiced in accordance with hospital policy. Refer to the
Infection Control Manual for specifications. Emphasis is placed on containment
of the “infective material”. Consult the Infection Control Department for
questions regarding patient placement.
6.19.4 Surgeons and anesthesia staff will notify the charge nurse of isolation patients and


RECOVERY ROOM
will specify type of isolation prior to admission to the PACU.

6.19.5 Patients on “Airborne Precautions” will be placed in a private room with negative
pressure ventilation.
6.19.6 Patients on “Contact Precautions” should be physically separated from other
patients and placed in a private room. If possible, provide 1:1 nursing staff
coverage while in the PACU. Gloves, gowns, and good hand washing will be
strictly enforced.
6.19.7 Personal Protective Equipment (PPE), gowns, masks, and gloves will be worn by
all personnel in accordance with the type of isolation category that applies to the
patient. If indicated, obtain an isolation cart from CSSD.
6.19.8 Personnel will always wear gloves for contact with blood/body fluids, open
wounds, drainage, or non-intact skin. Wash hands after gloves are removed
6.19.9 Disposable items will be used as much as possible and will be discarded in
accordance with hospital policy.
6.20 DISCHARGE FROM THE RECOVERY ROOM
6.20.1 Patients shall be discharged from the PACU by (a) a written order of the
anesthesia provider or (b) nursing personnel in accordance with Anesthesia staff-
approved discharge criteria.
6.20.2 The patient stay in the PACU may be curtailed or lengthened by anesthesia
provider as the patient’s condition dictates
6.20.3 Recovery care use written criteria and a numeric rating scale to determine the
patient’s readiness for discharge home or to an inpatient unit. The Aldrette Post
Anesthesia Discharge Score (PADS) is one measure of a patient’s readiness for
discharge
6.20.4 The PADS assigns a numerical rating of 0 to 2 for each of the following: vital
signs, activity level, nausea and vomiting, pain, and surgical bleeding. Patients
can be transferred to an inpatient unit with a PADS of between 8 and 10, but a
score of 9 or better is required if the patient is being discharged home
6.20.5 The Modified Aldrete’s Scoring (see attachment)
6.21 POST-ANESTHESIA INTERVIEW

6.21.1 A member of the anesthesia staff should interview all patients after release from
the PACU but before discharge from the hospital.
6.21.2 The anesthesia provider providing the anesthetic should perform the post-
anesthesia visit. If this is not feasible, he/she should arrange for another member
of the anesthesia or surgical service to interview the patient.
6.21.3 This interview should be performed the day following the anesthesia if possible.
If the patient is going to be discharged before the next workday, the interview
should be performed the same day that anesthesia is administered but after the
patient has been released from the PACU.


RECOVERY ROOM
6.21.4 The anesthesia provider is responsible for documenting the post-anesthesia

interview in the progress notes, indicating the presence or absence of any
anesthesia related complications as designated by departmental quality
improvement program. He/she should sign, date and time the note.
7. REFERENCES
7.1 Ministry of Health Standard Policies and Procedures.
FORMS/EQUIPMENTS
8.1 Equipment:
8.1.1. Cardiac monitor
8.1.2. Pulse oximeter
8.1.3. Humidified oxygen
8.1.4. artificial airway
8.1.5. ventilator
8.1.6. body temperature
8.1.7. BP Apparatus
8.2 Forms
8.2.1. Post Anesthesia Recovery Evaluation Form.
8.3 Attachment
8.3.1 Modified Aldrette Scoring
8.3.2 Level of consciousness
REVISIONS
9.1 This DPP entitled Anesthetic Post-Operative Care Recovery Room and numbered DPP-
AN-004 (4), is approved effective 28.07.2020, and shall be included in Policies and
Procedures Manual of Khobash General Hospital - Najran, and shall be reviewed every 2
years.
10. APPROVALS
10.1 Prepared by: Signature Date


RECOVERY ROOM
10.1.1 MS. KRISHNA RANI T. ________________ __________

OT Head Nurse
10.1.2 MR. HAMAD JAMIL ALKULEIB ________________ __________

OT Tech. Head
10.1.3 DR. MOHAMMED YAZID CHIAHI ________________ __________

Head of Anesthesia Department
10.2 Reviewed by:
10.2.1 DR. KHATER HAMAD AL AHMAD ________________ __________

QPSD Director
10.3 Approved by:
10.3.1 DR. ABDULMONEEM ALSHAYEB ________________ __________

Medical Director
10.3.2 MR. MESHAL GOJAH ALZAMANAN ________________ __________

Hospital Director
DPP-AN-004 (2) Page 10 of 10

Dpp-An-004 (2) Anesthetic Post-Operative Care Recovery Room

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Dpp-An-004 (2) Anesthetic Post-Operative Care Recovery Room

Uploaded by

Copyright:

Available Formats

Kingdom of Saudi Arabia ‫المملكة العربية السعودي‬

Ministry of Health ‫وزارة الصحة‬

Department: ANESTHESIA DEPARTMENT Original Date: 20.07.2018

2.1. All staff in the Anesthesia

DPP-AN-004 (2) Page 1 of 10

Department: ANESTHESIA DEPARTMENT Original Date: 20.07.2018

5.1. Anesthetist (resident)

DPP-AN-004 (2) Page 2 of 10

Department: ANESTHESIA DEPARTMENT Original Date: 20.07.2018

DPP-AN-004 (2) Page 3 of 10

Department: ANESTHESIA DEPARTMENT Original Date: 20.07.2018

6.10.9. Other parameters (depending on circumstances) e.g. temperature, urinary output,

DPP-AN-004 (2) Page 4 of 10

Department: ANESTHESIA DEPARTMENT Original Date: 20.07.2018

staff can quickly attend to patients. Proximity to radiographic, laboratory, other

6.16 PACU STAFFING:

DPP-AN-004 (2) Page 5 of 10

Department: ANESTHESIA DEPARTMENT Original Date: 20.07.2018

care, drainage catheters, and postoperative bleeding.

DPP-AN-004 (2) Page 6 of 10

Department: ANESTHESIA DEPARTMENT Original Date: 20.07.2018

boxes on the floor.

DPP-AN-004 (2) Page 7 of 10

Department: ANESTHESIA DEPARTMENT Original Date: 20.07.2018

will specify type of isolation prior to admission to the PACU.

6.21 POST-ANESTHESIA INTERVIEW

DPP-AN-004 (2) Page 8 of 10

Department: ANESTHESIA DEPARTMENT Original Date: 20.07.2018

6.21.4 The anesthesia provider is responsible for documenting the post-anesthesia

7.1 Ministry of Health Standard Policies and Procedures.

10.1 Prepared by: Signature Date

DPP-AN-004 (2) Page 9 of 10

Department: ANESTHESIA DEPARTMENT Original Date: 20.07.2018

10.1.1 MS. KRISHNA RANI T. ________________ __________

10.1.2 MR. HAMAD JAMIL ALKULEIB ________________ __________

10.1.3 DR. MOHAMMED YAZID CHIAHI ________________ __________

10.2 Reviewed by:

10.2.1 DR. KHATER HAMAD AL AHMAD ________________ __________

10.3 Approved by:

10.3.1 DR. ABDULMONEEM ALSHAYEB ________________ __________

10.3.2 MR. MESHAL GOJAH ALZAMANAN ________________ __________

DPP-AN-004 (2) Page 10 of 10

You might also like

10.1.1 MS. KRISHNA RANI T. ______

10.1.2 MR. HAMAD JAMIL ALKULEIB ______

10.1.3 DR. MOHAMMED YAZID CHIAHI ______

10.2.1 DR. KHATER HAMAD AL AHMAD ______

10.3.1 DR. ABDULMONEEM ALSHAYEB ______

10.3.2 MR. MESHAL GOJAH ALZAMANAN ______