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E. T. Shimber
MedicalDirector/ Chief Executive Director
Critical Careand Emergency Services Director/
ICU Director
ICU Laboratory
ICUpharmacy
Facility service
ICU Radiology
Biomedical
Critical care
physician
Physician crew
Fig. 11.1 ICU structure
Head nurse
Nursing
staff
Clinical
pharmasist
ICU Equipment
Common equipment in an ICU includes mechanical ventilators to assist breathing through an
endotracheal tube or a tracheostomy tube; cardiac monitors for monitoring blood pressure,
cardiac rate and rhythms; equipment for the constant monitoring of respiratory rate and pulmonary functions in patients on ventilators; a web of
intravenous lines, feeding tubes, nasogastric
tubes, suction pumps, drains, and catheters, along
with the various collection receptacles; syringe
pumps; and a wide array of intravenous drugs to
treat the primary condition(s) for which the
patient was hospitalized. Medically induced
comas, maximal analgesia to the point of anesthesia, and induced sedation are commonly
needed ICU tools which require specialized monitoring equipment and close nursing attention to
detailed observation. For further reading refer
Annex I.
Respiratory
thereapist
Nutritionist Physiotherapist
Monitoring inICU
Intensive care units rely heavily on continuous
monitoring and maintenance of patient’s vital
functions to improve survival and recovery of critically ill patients. Continuous monitoring of vital
signs permits identication of critical changes in
the patient’s progress and helps to guide therapeutic interventions. Early recognition of patient deterioration and timely intervention are critical in
saving patients’ lives and are the main reason to be
cared for in an ICU.Particular emphasis is placed
on the following:
Noninvasive Monitoring
• Vital signs—preferable continuous SPO2, BP,
Respiratory rate, Temperature and O2 ow
rate.
• Neurological function—GCS—format.
• Renal function—hourly/daily, input–output
balance.
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• Respiratory functions—adequacy of coughing, respiratory patterns, bilateral air entry
(check list on mechanical ventilator).
• Others including pain and response to pain
management—Analgesia protocol,
positioning, IPC protocols, nutritional status
documentation, relevant lab results.
Invasive Monitoring of Patients
• CVP.
• Arterial lines.
• ICP.
Monitoring of Equipment’s Function and
Sterility/Hygiene
• Amount of various drainages—NGT and
chest tubes, ow rate, and correct placement.
• Endotracheal tubes—position, xation, and
patency; dressing changes.
• Oxygen supply equipment (tanks)—empty,
full, ow meter, and backup BMV.
• Perfusers’ functionality, availability, and electric connectivity.
• Infusions—type of uid, infusion rate, label
(type, time, rate of ow) and hand covering
format.
• Folly catheters—urine output amount every
12h; day of insertion and functionality.
• Suction devices—amount of drainage from
suction tubes; suction machine sterility and
functionality and dressing change.
• Emergency drugs—daily inventory—availability and crush cart resupply.
• Mechanical Ventilator—monitor for the following parameters: VT, RR, MV, FIO2, PEEP,
Mode, I: E, PSV, patient synchrony; check
daily for Alarms, humidiers, Tubing, Filters,
Power, Cleanness, and Safety.
Specic Medical Conditions
Shock: Patients with shock are initially admitted
to the emergency department (either Adult or
Pediatric). Institution-based protocols considering the availability of resources should be followed for individual patients. Overall uid
resuscitation starts based on the etiology of the
problem. Nonresponders will be started on inotropes after a major effort at determining the
diagnosis but not delaying treatment to achieve a
favorable outcome. Mostly the available drugs
are Adrenaline and Dopamine. For septic shock
patients, broad-spectrum antibiotics are usually
initiated before a sample for blood culture is
obtained, since the microbiology lab is limited
for selected critical patients. Oxygen is provided
intra-nasally or via face mask, either from concentrator machines or oxygen cylinders based on
availability. Serial follow-up is made by nurses,
medical interns, and residents with consultants as
needed, especially surgeons who are also responsible for newly coming emergency patients. Since
monitors are not readily available in emergency
and intensive care rooms in LMICs pulse oximetry and manual blood pressure cuffs are used routinely. This makes the follow-up laborious and
inadequate. Baseline Laboratory investigations
are done when a laboratory is available, while
ECG and ultrasound evaluations are also desirable when available in station hospitals in LMICs.
Culture for blood and body uids can also be
obtained more readily at initial meeting prior to
antibiotics and transfer to an ICU.Patients continue to obtain adequate cardio-respiratory support and serial follow-up while being investigated
for a precise diagnosis, either surgical or medical
in a better-focused manner, with appropriate consultations as necessary. Manual debrillator is
usually available in an emergency room, but not
routinely used, frequently because it needs repair
and/or lack of training in its use. Another possible reason is late detection of cardiac arrests due
to poor minute-to-minute follow-up in an understaffed busy setting.
shortage of supplies, and lack of biochemical and
microbiologic prole measurements are some of
the limitations in ICUs in LMICs, especially in
remote station and even in regional hospitals, but
rarely in tertiary centers.
directed to emergency departments, just like
patients with shock. Medical interns and emergency room residents provide the rst evaluation,
collaborating with specialists as necessary. Based
Scarcity of equipment, trained personnel,
Sepsis: Patients with sepsis are initially
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E. T. Shimber
on locally adapted Surviving Sepsis Campaign
guideline, patients are resuscitated and empirical
antibiotics are administered, usually before a
sample for culture is taken (forgetting to do this is
a major error which must be avoided). Basic laboratory testing, targeted radiologic examinations,
and focused ultrasound tests are used to investigate these patients. Because of limited access,
lengthy lineups, and local emergency service
constraints, most patients with sepsis in LMICs
progress to septic shock. Admission to ICU is
usually prioritized for other critically ill patients
due to the inadequate number of ICU beds unless
these patients deteriorate to septic shock at which
point, they may get the privilege of critical care
unit management or get to the operating room if
surgically indicated.
Arrhythmia: Dysrhythmia is often fatal due to
failure to detect it or because of lack of appropriate anti-arrhythmic drugs that can be used in a
timely fashion. Detailed knowledge of ECG
interpretation as well as understanding of classication of type of arrhythmias is the rst and
critical step in leading the intervention.
Unfortunately, this is frequently not recognized
by staff in station or regional emergency areas in
LMICs where adequate cardiac monitoring is
rare. The commonest types of arrhythmias are
atrial brillation, supraventricular tachycardia,
and ventricular tachycardias. The widely available anti-arhythmic agents include digoxin, adenosine, amiodarone, and metoprolol, which are
frequently not readily available in emergency
rooms but must be available in the ICUs.
ment’s procurement approach usually does not
facilitate acquisition of necessary resources. The
exorbitant cost of treatment, which is frequently
unaffordable for the majority, prevents admissions to ICUs and results in even greater cost in
lives and loss of the workforce. This is partially
due to an inadequate health insurance system
and/or minimal universal health care. The staff
generally has low motivation, lack of satisfaction
because of lack of enthusiasm for ICUs by health
authorities. This in turn leads to a vicious cycle of
decreased specialized knowledge, and experience. Determination of priority of admissions to
the limited number of ICU beds raise signicant
ethical issues. Delayed referral systems and late
initiation of care signicantly affect the outcome
of the critically ill. Lack of preventive and corrective maintenance of equipment due to the absence
of supplies and biomedical staff shortage hinders
the delivery of optimal care.
The lack of accurate patient data from
dened regions and countries and the shortfall
in human resource management will be
addressed by the growth of technologic tracking and by the specialized training of highly
competent young professionals. The interest of
the international health community in assisting
in improvement of critical care in this environment should help to advance ongoing efforts.
Introducing ICU professional skills and novel
technologies to the existing system will further
improve the care of the sickest patients.
Vigorous advocacy, policy change, and a paradigm shift are required to address the critical
care challenges in LMICs.
Challenges andFuture Directions
forICUs
Operating critical care services in LMICs presents signicant problems, in contrast to ICUs in
HICs. These include nancial constraints, scarcity of trained personnel, both doctors and nurses,
restricted infrastructure for transportation, technology, communication, and administrative leadership. Even if the sufcient support was
available, access to essential medications and
supplies remains generally limited. The govern-
Conclusion
The intent of this chapter is to provide a brief
road map on how to approach the establishment
of an ICU in various areas of an LMIC, depending on the sites and types of hospitals, ranging
from rural station hospital to regional hospital in
a larger city, to tertiary centers in capitals and
large urban areas, the emphasis is on training
and employment of expert intensivists and/or
providers of critical care by other specialists.
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Emphasis is also placed on training and expertise of nursing and other ancillary staff, on nurse/
patient ratios, on availability of supplies and
equipment, and on staff interaction and collaboration with consultants and other caregivers.
Appropriate stafng is adjusted to the size and
type of ICU which may be multidisciplinary or
specialty focused and will vary as to size and
stafng according to the type of hospital it subserves; this includes the tertiary type as most
advanced and the largest, regional which is
smaller, and the station hospitals which are
smallest and least advanced, usually found in
rural areas. Laboratory, radiology, anesthesia,
and specialist support for the different ICUs also
vary in availability from most advanced hospitals to the smallest station hospitals. To achieve
signicant progress in this area, public and government enthusiasm is required to provide nancial, technical, professional, and health care
community collaboration and support.
Annexes
Annex I
List ofequipment
• 24-hours monitoring and the provision of
oxygen
• Adequate lighting for bedside procedures.
• Anesthesia machine.
• Arterial line monitoring.
• Bag valve mask.
• Beds with removable headboard and adjustable position.
• Blood Analyzer.
• Central venous catheters, arterial catheters.
• Central venous pressure monitoring devices.
• Chest tube, pigtail catheter, chest drainage
system.
• Continuous end-tidal CO2 monitoring.
• Continuous pulse oximetry.
• Debrillators.
• Dialysis unit.
• Difcult airway management equipment.
• Echocardiography and ECG.
• Emergency resuscitative equipment.
• Fluid and bed warmers.
• Foley catheters.
• Hypo/hyperthermia blanket.
• Infusion pumps.
• Insert tons of airway equipment here such as
direct laryngoscopes, Glide Scopes, bougies,
etc.
• Insert tons of wound care supplies.
• Intra cranial monitoring devices.
• Nasal cannula (including high ow), nonrebreather masks.
• Nebulizer.
• Non-invasive monitors.
• Non-invasive positive pressure ventilation
(e.g. BiPAP, CPAP) machines.
• Oxygen concentrators, oxygen cylinder, concentrator with ow meter.
• Paracentesis kit.
• pericardiocentesis set,
• Portable Clinical Lab. Devices.
• Portable light.
• Portable X-ray machine.
• Sterile gowns and sterile drapes.
• Suction machines including Yankauer tips.
• Telemedicine capability.
• Telemetry.
• Thoracentesis kit.
• Tracheostomy set.
• Transvenous pacemaker kits and external
pacemaker device.
• Ultrasound machines.
• Ventilators and monitors.
• Weight scale.
Annex II
ICU quality indicators
1. Compliance with hand hygiene protocols
2. Providing information to families of patients
in the ICU
3. Appropriate sedation
4. Appropriate pain management
5. Appropriate sepsis management
6. Early enteral nutrition
7. Prophylaxis for GI bleed in those undergoing
invasive mechanical ventilation
8. Inappropriate transfusion of blood products
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E. T. Shimber
9. Semi recumbent position for patients on
invasive mechanical ventilation
10. Ventilator associated pneumonia
11. Prevention of catheter related bloodstream
infections (CRBSI), and catheter associated
urinary tract infections (CAUTI)
12. Early administration of acetyl salicylic acid
in acute coronary syndrome
13. Early reperfusion therapy in STEMI
14. Monitoring ICP in severe traumatic brain
injury with CT ndings
15. Surgical intervention within 3h in traumatic
brain injury with subdural and/or epidural
hematoma
16. Perceived Quality Survey at discharge from
ICU
17. Presence of ICU trained medical professionals in the ICU
18. Maintaining adverse events register
19. Length of stay
20. Tracheotomy rate
21. Mortality rate
22. Pressure ulcer
23. Rational use of antibiotics (development of
drug resistance)
24. Readmission rate
25. Re-intubation rate
26. Fall rate
27. Presence of CC trained pharmacist/clinical
pharmacists
28. Presence of key ICU drugs and supplies.
References
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JV, Dorman T, etal. What is an intensive care unit?
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How toCreate aPost Anesthesia
https://t.me/medicina_free
Care Unit forRecovery After
Surgery andAnesthesia inaLowandMiddle-Income Country
TriciaBrentjens andRebeccaHavlirMartinez
They may forget your name, but they will never forget how you made them feel.
– Maya Angelou
Abbreviations
BP Blood pressure
ECG Electrocardiogram
HICs High-income countries
ICU Intensive Care Unit
LMICs Low- and middle-income countries
ORs Operating rooms
PACU Post Anesthesia Care Unit
POCUS Point of care ultrasound
PONV Postoperative nausea and vomiting
RNs Registered nurses
RR Recovery room
RR Respiratory rate
T. Brentjens (*)
Department of Anesthesiology, Columbia University
Irving Medical Center, New York, NY, USA
e-mail: tb164@cumc.columbia.edu
R. H. Martinez
Department of Anesthesia and Critical Care
Medicine, University of California, San Francisco,
San Francisco, CA, USA
e-mail: rebecca.martinez2@ucsf.edu
12
Introduction
Once patients have completed their care in the
operating room, healthcare centers usher patients
to a formal area for their initial recovery from
anesthesia and surgery. Often termed a Recovery
Room (RR) or Post Anesthesia Care Unit (PACU)
these areas serve primarily to monitor patients in
the immediate postoperative period after surgery
as they emerge from general or regional anesthesia or sedation, providing vital medical services
to patients and enhancing the safety and efciency of the hospital system. Common postop
issues include respiratory depression, hemodynamic instability (hypo/hypertension), postoperative nausea and vomiting (PONV), pain control,
altered mental status, shivering and monitoring
for postop bleeding.
The rst PACU was established in the 1940s
in the post-World War II era as surgical interventions and repairs became more common and survivable. Initially, RRs were poorly funded and
staffed. However, backed by an intensive governmental investment in improving the standard of
health care, these areas of the hospital quickly
ourished. Establishing RRs became a priority
after abysmal rates of post-anesthesia complications were reported in 1947in the Journal of the
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. A. Hardy, B. R. Hochman (eds.), Global Surgery, https://doi.org/10.1007/978-3-031-28127-3_12
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American Medical Association. This 11-year retrospective study identied 47% of anesthesiarelated postoperative deaths as preventable. The
commission recommended clustering patients
together in the immediate postoperative period
for improved direct observation of patients,
which was predicted to prevent 33% of all postsurgical deaths [1].
Thus, the PACU was born to serve as an observational unit where nurses provide specialized
postoperative care with physician oversight. The
combination of skilled nurses trained to recognize and intervene in common post-anesthetic
and surgical complications as well as physical
proximity to the operating rooms where physicians remain actively engaged in caring for other
patients facilitates the rapid identication and
response to respiratory and hemodynamic instability, greatly improving patient safety.
Indeed, the core mission of the PACU to facilitate safe care of the post-anesthesia and surgical
patient has remained the same nearly a century
later and applies equally in high-income countries (HICs) and in low- and middle-income
countries (LMICs). PACUs have been shown to
enhance recovery from anesthesia and are correlated with improved surgical outcomes [2]. This
is in part because a PACU clusters patients who
have a higher likelihood for acute events that
require early intervention and occasionally
immediate emergency response; it is therefore
staffed by professionals trained in the recognition
and response of postoperative complications.
PACUs also have transitioned to areas of the hospital that are optimal for triage as occasionally it
is unknown if during the post-surgical period a
patient will progress toward a trajectory of stability or deteriorate requiring a higher level of care
than can be offered on a traditional inpatient ward
[3].
Beyond what was traditionally envisioned,
PACUs also have been recognized to facilitate
optimal healthcare resource utilization. As
patients can be ushered out of operating rooms
and recover from anesthesia in a separate space,
RRs allow “hospitals to improve their caseloads,
reduce turnover times in the operating room, and
even help to manage a shortage of beds in the
intensive care unit” [4]. The exibility offered by
PACUs as areas that can be transformed to provide critical care space in times of extreme hospital duress and capacity was demonstrated most
recently during the 2020 Sars-CoV-2 pandemic
which tested the capacity of healthcare delivery
systems worldwide. During localized case surges,
existing PACUs were supplemented with personnel and services, and then converted into full
intensive care units (ICU) [5].
In this chapter, we will review the essential
components to establish and run a functional
PACU.There will be attention given to setting up
the physical space, personnel and training
requirements, a very brief review of some common emergency scenarios, and nally steps
toward perpetual quality improvement.
Physical Space andEquipment
The PACU should be located in close physical
proximity to the operating rooms (ORs) which
both minimizes transport times between operating rooms and the recovery area and allows for
rapid response by additional staff in the case of
an emergency and for possible return to the
OR.PACUs are primarily open units with ideally
one or two enclosed private rooms designed for
patients in need of strict contact or airborne isolation needs. This facilitates a “shared care” model
where providers in or walking through the PACU
can quickly evaluate a patient and recognize
changes that require attention and intervention.
PACUs should have delineated spaces for each
patient, ideally with a bed or a reclining chair. As
with all units, natural light as well as sufcient
airow is optimal for patient safety and satisfaction, though as patients often spend only limited
periods of time in the RR, these qualities can be
prioritized less when necessary.
The monitoring of vital signs is an important
component of delivering safe care in the PACU.A
variety of equipment should be available for use
in both monitoring and to intervene in emergency
situations. Ideally, the PACU should have the
ability to continuously monitor electrocardiogram (ECG), oxygen saturation, and intermittently
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monitor blood pressure (BP), respiratory rate
(RR), and temperature. The most critical monitor
is perhaps the pulse oximeter which can provide
both a heart rate and blood oxygen saturation.
Interestingly, continuous pulse ox monitoring
was not found to decrease mortality [6], suggesting that intermittent checks combined with routine physical exams for cyanosis may be
sufcient. Rapid availability of either manual or
automatic BP monitoring is also essential as
hemodynamic changes can be a harbinger of
pending distress. It is preferable to have continuous ECG monitoring for all patients, especially
those at high risk for arrhythmias or ischemia. In
an ideal situation, all monitors would send data to
a central monitoring area where one person can
observe changes and initiate prompt bedside
response to deviations from expected values,
although we realize that this is not likely in many
global healthcare situations in LMICs.
Equipment necessary for respiratory and airway support should be kept in the PACU as well
as the operating room areas if feasible. Nasal
cannulas and facemasks are necessary to provide
supplemental oxygen. Ideally, every patient spot
in the PACU would have an oxygen supply but
we realize that in LMICs this may not always be
possible and recommend the availability of portable oxygen tanks (safely and secured stored and
checked regularly). Necessary items for airway
support include: a bag-mask-valve system, oral
and nasal airways, laryngeal mask airways, endotracheal tubes, intubating blades, boogies, and an
end-tidal carbon dioxide colorimeter. More specialized airway equipment such as a video laryngoscope may provide further safety for patients
requiring reintubation. A variety of styles are
available on the market including the CMAC,
Glidescope, and McGrath, though each of these
requires a system either to sterilize specialized
blades and/or replaceable components that are
single-use only. Fiberoptic bronchoscopes provide a level of additional safety but are incredibly
resource intensive in terms of both physical
maintenance and routine staff familiarity with
their safe usage; these scopes, if available, may
be better suited in a designated operative space
and transported to the PACU in case of emer-
gency. If wall suction is not available, ideally a
source for portable suction should always be
available.
One technology worth potentially investing in
is ultrasound. This imaging modality has signicant diagnostic and therapeutic utility. Evolving
technology includes handheld ultrasounds which
plug into smartphones and require minimal maintenance and are relatively inexpensive. Point of
Care Ultrasound, POCUS, has become an
increasingly popular tool to allow prompt diagnosis of many conditions. Lung POCUS can easily diagnose pulmonary congestion,
pneumothorax, or pleural effusion. Cardiac
POCUS can allow for a quick assessment of
global function, wall motion abnormalities, and
pericardial effusion. Abdominal POCUS can
assess for volume status and free uid. It has
been shown that ultrasound availability in the
PACU narrows the differential diagnosis as well
as decreases the length of stay in the PACU [7].
While ensuring proper training of the person
interpreting the images is paramount to safe use
of the technology, multiple free resources are
available online from sites such as YouTube.com
and nysora.com among many others (see Chap.
18).
Personal protective equipment for staff such
as gloves and masks should be stored in this area
along with bed linens. Gloves and supplies should
ideally be latex free as many patients and healthcare professionals have latex allergies. Separate
clean and dirty utility areas should be maintained.
Necessary supplies range from routine wound
care supplies including gauze, dressing supplies,
and tape to supplies for vascular access including
tourniquets, alcohol wipes, angiocatheters, and
needles in a variety of gauges. Fluids, such as
normal saline and lactated ringers, as well as IV
tubing should be available. Syringes are needed
for both the administration of medications and
drawing of blood. Laboratory tubes for available
blood tests should be stored. Each item should
have a designated space that is well labeled to
facilitate both ease of access and prompt identication of low-supply count. Storage of supplies
in a centralized well secured area that is conveniently located to minimize foot trafc by nurses
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T. Brentjens and R. H. Martinez
out of the immediate care vicinity of the patients
is ideal. This area should be well protected from
illegal entries and theft which may be very tempting for the patients and for the staff. Other equipments to consider are oro- and nasogastric tubes,
foley catheters, and chest tubes. Bakri balloons
may be lifesaving and should be prioritized to
provide care for the patient with post-partum
hemorrhage. An example of a cart system to
organize supplies is shown in Fig.12.1.
The availability and storage of routine and
emergent drugs used in perioperative care is
extremely important. Commonly used medications for administration in the recovery room
include opioids for pain control (fentanyl or morphine being preferable because of long shelf life
and easy storage), non-opioid analgesics (including paracetamol and ibuprofen), anti-emetics
such as ondansetron and metoclopramide, and
antibiotics. As some of these drugs can be habitforming if improperly administered, it is recommended that a system to minimize abuse be
implemented and maintained for staff and patient
safety. Additionally, medications to treat hypertension, hypotension, and bronchospasm should
also be available. These include rst-line drugs
such as epinephrine and atropine; second-line
drugs may include phenylephrine and ephedrine.
Albuterol inhalers and or nebulizers for treatment
of bronchospasm should be stocked.
Personnel, Roles, andTraining
Successful operation of a PACU begins in the
preoperative area and in the operating room. In
these spaces, high-risk patients can be optimized,
analgesia can be administered, and a plan for the
recovery can be formulated. The person providing care for the patient in the operating room
should accompany the patient to the recovery
area and provide a sign-out to the primary PACU
provider, usually a specialist nurse, including a
brief medical history, allergies, surgery overview,
anesthesia overview, complications intraoperatively, and a plan for anticipated postoperative
course, including orders for any pain and nausea
control regimens.
The PACU should be overseen by a trained
physician, typically an anesthesiologist or anesthetist, or a pulmonologist. Depending on the
training system where the hospital is located, the
senior-most person may be a physician or a nurse.
Providers with this training are best equipped to
lead a team response to both common and major
events of instability. Their primary role is to oversee the functioning of the unit and respond to
emergencies. Many times, the supervising anesthesiologist may continue to provide routine care
to other patients in the operating room, but a system should be in place to make this person
immediately available to respond and provide
Fig. 12.1 An example
of locked storage
systems for organizing
and containing basic
supplies that may be
helpful in the care of the
PACU patient
12 How to Create a Post Anesthesia Care Unit for Recovery After Surgery and Anesthesia in a Low…
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care and treatment of patients in the recovery
area.
The primary providers of care in the PACU are
the nurses. Ideally, one nurse would be assigned
to care for no more than four patients at a time,
although this ratio will depend on the acuity of
the patients and the amount of support available.
If a patient is critically ill, they may even require
1:1 care. Nurses serve a variety of critical roles in
caring for patients in the recovery room. Nurses
assess the patient for hemodynamic stability,
acquire regular vitals, perform physical exams to
monitor for bleeding and other postoperative
complications, evaluate patients for pain and
nausea and provide medication as needed per
postop orders, draw labs, assess for cognition and
recovery from anesthesia and readiness to transition out of the PACU.Nurses are typically the
rst-line providers to initiate a call to action when
recognizing a deteriorating patient. Indeed, communicating their critical ndings to the supervising practitioner is among the important roles
nurses serve in the PACU.
Nurses, given their direct bedside roles, also
often serve beyond the role of care providers in
the recovery room: they are often the frontline
communicators with patients and their families.
While surgeons typically discuss with patients
and their families a summary of a patient’s surgery, logistically, this task often falls on the
nurses who are more readily available at the bedside to answer questions. Nurses should be comfortable answering questions that are standard
practice in their clinical setting, but should also
feel supported in reaching out to the lead physicians who may have more specic answers to any
questions. Communication by the nurse is therefore not only between healthcare providers but
also between the patient and the healthcare
system.
In terms of more advanced procedures, the
role of nurses in the recovery room and their
scope of practice varies widely based on region.
A review of multiple international hospitals
found a wide range of supervision required for
nursing care [8]. For example, while most nurses
do not supervise patients on ventilators independently, at some institutions this is common. It is
important that the scope of practice of the nurses
in the PACU be established and clear in order to
provide appropriate educational and logistical
support to those undertaking more specialized
responsibilities. As there is a high level of potential acuity in the PACU, it is recommended that
PACU nurses not only have a solid foundation of
nursing knowledge and experience, but also
undergo additional orientation and continuing
specialist education prior to caring for patients
and during their stay in PACU. Training for a
nurse should include a period of shadowing their
colleagues to understand the logistics, set up and
ow of the space, and an understanding of common emergency scenarios and responses. It is
advisable that PACU RNs spend some time orienting in an ICU setting to gain more familiarity
and expertise monitoring these types of patients.
It is recommended that nurses in the PACU be
competent and comfortable in participating in
advanced cardiac life support. Many times PACU
nurses are those who have already practiced care
delivery in the ICU but are interested in a career
shift.
Ancillary staff also provide critical elements
of safety to the patients in the PACU. Trained
pharmacists may be able to assist in medication
prescription, reconstitution, and administration.
People who are on the environmental service
team can ofoad work from the usually busy
nurses by ensuring the space remains clean and
safe. Notably, families may also at times ll this
role and provide simple food to facilitate recovery when appropriate.
Common PACU Issues
andEmergencies
Common postoperative issues include respiratory
depression, hemodynamic instability (hypo/
hypertension), PONV, pain control, altered mental status, shivering and monitoring for postoperative bleeding. The rst step in any emergency
response is to ensure staff safety and communicate a need for assistance from a broader team.
There are a multitude of emergency scenarios
that may occur in the PACU.We recommend that
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