Fig. 6.1
(a, b) A traditional PACU square open-ward design, (c) the PACU bed-spaces and [white arrows] the standard bright fluorescent ceiling lights
Fig. 6.2
The stored PACU supplies in baskets on the head wall
The available designs for the patient’s bed slots include:
Lined up along a wall where the utilities come from the wall by the patient’s head (Fig. 6.1).
“Pods” of four beds at 90° angles located in the middle of a large space. The utilities drop from the ceiling or come up into a tower-like utility tree at the centre of the four patients’ heads allowing one or two nurses to have immediate access to deliver care with little time or effort lost walking from bed to bed [4].
Additionally, the design of the PACU must accommodate permanent and prominent places for emergency carts (resuscitation, airway and surgical equipment particularly for thoracic patients) (Fig. 6.3) and a significant storage space (Fig. 6.4a–c).
Fig. 6.3
The emergency PACU cart
Fig. 6.4
The storage space in the PACU. (a) Cabinets including blankets, linens and fluids; (b) drawers including commonly used medications in the PACU; and (c) a cabinet and a cart including medications
Ideally, there should be at least one isolation room that has a connecting door with the main PACU area and another door opening out to a hospital corridor, allowing separation patients with resistant infections or severely immunocompromised patients from the general PACU population. It can be equipped with an air-handling system that can be changed literally [4].
6.1.4 PACU Traffic
The orientation of the PACU should facilitate the flow of patients allowing direct entrance to the PACU from an OR corridor and a preferably separate exit to a main hospital corridor. Whereas, the use of the same PACU door for both entrance and exit may inevitably lead to traffic jams and potentially dangerous situations [4].
Both the entrance and exit doors must be extra wide to guarantee the passage of a full-sized hospital bed with an ECMO/intra-aortic balloon pump console and people pushing IV poles on both sides. The doors could be automatically opened by a push button on the wall or by motion sensors [4].
It would be desirable to include a separate “pedestrian entrance” distinct from the doors used for patient entrance and exit. This could facilitate movement of staff and visitors and minimise distracting traffic jams, “whooshing” of the doors and the introduction of contaminated air from other parts of the facility [4].
6.1.5 PACU Bed-Spaces
It is a standard to budget a total of about 150–200 sq. ft. for each patient bed slot separated with ceiling-to-floor privacy curtains between the bed-spaces to ensure the patient privacy in the PACU as shown in Table 6.1 and Fig. 6.1c. Each bed slot needs to be equipped with a pull-chain emergency call buzzer, allowing patient to call the PACU nurse when step away from the side of the bed or allowing the PACU nurse to call attention in emergency without yelling and alarming other patients in the room [4].
Table 6.1
PACU bed-space
A floor space to the actual bed slot itself | ≥100–120 sq. ft. |
A working space to the nurses around all four sides of a bed | ≥3 sq. ft. |
A shelf space to supplies and equipment | ≥12 sq. ft. |
A writing surface nearby such as a rolling tray table | |
A floor space to IV poles or more convenient ceiling-track-mounted IV poles | |
6.1.6 General Considerations of the PACU
6.1.6.1 Layout
Two fire exits at opposite ends of the room are recommended in addition to compliance with the institutional fire codes.
A nonslip tile floor in one neutral colour allowing finding dropped objects (e.g. needle), and light, neutral, “warm” colours for the walls are usually suggested (Fig. 6.5a).
Fig. 6.5
(a) A nonslip tile floor of the PACU and (b) a handwashing tool in the PACU
Multiple synchronised clocks to the same time should be readily visible from all locations in the PACU.
A handwashing sink for each six bed slots is strongly recommended (Fig. 6.5b).
A medication room or area including a cabinet or carts is required (Fig. 6.4c).
Two separate utility rooms with storage areas should be incorporated into the plan:
The clean utility area includes a large blanket warmer (Fig. 6.4a).
The dirty utility area should have three separate sinks for regular use, instrument washing and flushing and a separate door to an outside corridor, allowing removal of trash and contaminated waste and dirty linen without carrying it past patients in the PACU.
Staff support space including:
Adequate number of staff lavatories to the size of the staff, which should be separate from any patient facilities.
A staff break area is necessary and it could be equipped with a sleeve patient’s monitor and alarms heard allowing continuous patient’s observation while staff members are on break.
An adequate desk space for physicians and staff to write notes or dictate, including adequate number of terminals, if a computerised information system is in use (Fig. 6.6a).
Fig. 6.6
(a) A PACU desk space for physicians and nursing staff to write notes, a telephone line [A white arrow], a computer terminal and a central patients monitor and (b) a bedside and (c) portable suction equipment
Office space for the head nurse is a highly desirable addition (Fig. 6.6a).
6.1.6.2 Equipment and Drugs
The equipment and drug supplies should be stored and available in the PACU, including suction equipment and oxygen supply sources at each bed (Figs. 6.2, 6.4c and 6.6b, c).
A respiratory oxygen delivery system should be available for use in the transport from the OR to the ward, to high-dependency area or the ICU.
6.1.6.3 PACU Lighting
It is desirable to have some daylight visible to patients in the PACU that has the potential to reduce the postoperative cognitive dysfunction(POCD) [5]. Otherwise, the standard bright fluorescent lights are used in ceiling fixtures (Fig. 6.1c).
Each bed-space needs enough levels of controllable lighting within the bed-space.
A low-level night light is required for observation of a sleeping patient when the unit is otherwise quiet to minimise the incidence of POCD [5].
In addition, the PACU should have at least one portable light that can be moved to any bed slot to facilitate any needed procedures.
6.1.6.4 PACU Environment
(The average temperature in a PACU should be about 75 °F (24 °C) to avoid aggravating OR- induced hypothermia, despite cooler temperatures, may be favoured by the staff.)
The relative humidity should be maintained at 40–60 %.
The heating, ventilation and air conditioning system of the PACU should be set to include a slight positive air pressure in the PACU, discouraging entering bacteria from outside the PACU. There should be a minimum of six air changes per hour, two of which are fresh outside air.
6.1.6.5 Electrical Power
At least six to eight regular outlets should be available on the head wall or on the utility centre for each bed-space. At least two of them should be clearly marked with red face plates and connected to an emergency power system that has a kick-in time of <10 s following a power failure.
A supply of flashlights and battery-powered lanterns should be available to avoid total darkness in the case of the power failure in which the emergency power also fails.
Ventilators and infusion pumps for vasoactive drugs should always be plugged into emergency outlets.
Additionally, several 240-volt plugs allowing the use of portable X-ray machines should be available.
6.1.6.6 Medical Gases
The standard regulations for all medical gas installations must be considered.
There should be at least two to three oxygen outlets (one having a flow meter installed at all times) on the head wall or utility tree for each bed slot.
Three to five suction outlets should be available at the head of each bed slot for tracheal suction, gastrointestinal suction, chest tubes, drains and airway or surgical emergencies (Fig. 6.6b, c).
There should be one compressed air outlet at each bed-space to be used as a blender for a ventilator.
6.1.6.7 Central Equipment in the PACU
One or more full resuscitation or “code” cart, including external and internal defibrillating paddles, is needed for the thoracic patients depending on the size of the unit (Fig. 6.3).
Both external and transvenous pacing electrodes and generators should be available.
The difficult airway cart that should be kept in every PACU containing a complete array of airway equipment, including a videolaryngoscope, a fibre-optic bronchoscope and a light source.
A mechanical ventilator could be permanently kept in the PACU or to be ready for rapid deployment when needed.
A number of surgical trays and supplies should be available at the PACU at all times, including thoracostomy and tracheostomy trays and chest reopening set because there is usually not enough time to have them brought in from the OR in crisis cases.
6.1.6.8 Essential Equipment for Each Bed-Space
All stretchers used for patients in the PACU should be capable of a head-down and semi-setting positions. Usually, having one stretcher per bed-space is not enough, because it is unlikely the left stretcher with the discharged patient to be returned in time to be ready for the next patient to be transferred from the OR to that PACU bed-space.
A self-inflating resuscitator bag, a stethoscope and a warming device rather than the traditional heated blankets should be available near the head of each bed-space at all times.
Spirometers and negative inspiratory force meters must be enough so that they are readily available when needed.
Other items that should be immediately at hand include a pressure bag for rapid IV infusion, blood tubes, blood gas kits, basic nursing equipment (e.g. emesis basin, gauze, gloves, eye protectors, pads, tape, IV equipment, etc.) and tools (e.g. scissors, a clamp set, possibly a suture set, etc.).
6.1.6.9 Patient Monitoring
The recommended ASA standard monitors for all admitted PACU patients include an electrocardiogram monitor, heart rate, a non-invasive blood pressure module, a pulse oximeter, respiratory rate and a rapid-acting electronic thermometer [6].
All of the PACU monitors should have invasive pressure channels for patients undergoing thoracic procedures. Vital signs are recorded as often as necessary but at least every 15 min while the patient is in the PACU.
At least one capnograph immediately should be available to monitor ventilation in a seriously ill patient or verify correct tracheal intubation.
A dedicated cardiac output computer must be available if pulmonary artery catheters are used.
There should be at least one peripheral nerve stimulator with TOF and double-burst capability in the PACU to identify patients with PORC, defined as a TOF ratio <0.9, which may occur in 22–60 % of patients in the PACU.
Computerised patient data management systems have been widely used, into which data can be entered by either direct capture of monitor signals or entry by the PACU nurses or physicians.
6.1.6.10 PACU Communications
An inadequate number of telephones is a common problem in the PACUs. Cordless telephones can be quite useful, since they allow the nurse to talk on the telephone without leaving the bedside.
Of note, the main telephone at the PACU desk needs to be as free as possible for incoming calls.
It is advisable to have a different telephone number from the main number to be used only by the OR circulating nurses to inform the PACU about impending patient transfers to the PACU.
A dedicated intercom system exclusive to the surgical suite area is a potential alternative, which may or may not tie into the OR overhead paging system.
Another option is to use two-way voice communication devices utilising the hospital wireless network, voice recognition and wearable equipment allowing the PACU nurse to continue taking care of the patient at the bedside without a cordless phone.
More recently, a dedicated alarm system that would summon help in a crisis (e.g. code situation) involving a large (often red) button under a clear plastic cover at the desk or on the wall in a central location in the PACU is considered to activate light and bell alarm in the OR and in the place most likely to be populated by anaesthesia personnel who can respond immediately.
6.1.7 Staff
Ideal staff should consist of:
An anaesthesiologist should be assigned to be responsible for final medical decisions in the PACU (i.e. respiration, circulation, fluid, metabolic balance and analgesia).
An expert charge nurse in the advanced cardiac life support directs the PACU, acts as a backup care nurse when the PACU gets busy and supervises the minute-to-minute operation [7].
Skilled PACU nurses trained in airway management, basic life support and dealing with the unique patients emerging from anaesthesia after thoracic procedures (e.g. caring for acute surgical wounds and a variety of chest drains) should be capable to provide the direct early postoperative patient care. Usually, it is necessary to have one PACU nurse caring exclusively for each patient undergoing thoracic procedure, at least for the initial 15 min in the PACU. After that, patients who are conscious and stable can usually be monitored by a nurse who is simultaneously watching one similar patient. Patients who are stable, awake, alert and uncomplicated who have been in the PACU for more than 30 min can be watched even less closely. On contrary, patients who are unstable or who have complications (e.g. hypoventilation) require constant close monitoring regardless how long they have been in the PACU [8]. Classically, the PACU nurses take at least 60 min to admit a patient, manage the patient’s recovery, get the patient ready for discharge from the PACU and complete all the paperwork.
The operating surgeon is responsible for decisions about the results of the performed thoracic procedure.
6.1.8 PACU Discharge Criteria
Discharge of patients after thoracic procedures from the PACU to the ward or high-dependency unit is usually the responsibility of the physician or PACU nurse according to the institutional policy and discharge criteria (Table 6.2) [4]. Brown et al. reported shortening the PACU stay by 24 % with using these predetermined discharge criteria [11].
Table 6.2
Discharge criteria from the PACU to the ward
1. He/she is alert |
2. Oriented to the time and place |
3. Conversant and cooperative |
4. If vital signs have been stable for at least 30 min |
5. The patient could sit up without dizziness or nausea |
6. The pain is considered tolerable, and the modified Aldrete score is ≥ 9 [10] |
7. Outpatients should be discharged to a responsible adult who will accompany them home |
8. Outpatients should be provided with written instructions regarding postoperative diet, medications, activities and a phone number to call in case of emergency |
6.2 What to Treat in PACU?
There is an emphasis on the adverse events occurring in the PACU after thoracic procedures such as airway obstruction, aspiration of vomitus and inadequate ventilation from residual curarisation. Interdisciplinary rounds in the PACU can potentially reduce these complications through improved quality of care and effective communications between physicians, house and nursing staff [12].
6.2.1 Early Postoperative Complications
6.2.1.1 Postoperative Nausea and Vomiting (PONV)
The PONV has an overall 20–30 % incidence of patients undergoing general anaesthesia. PONV has a significant negative effect on patient satisfaction with anaesthesia, and even it may cause severe complications such as Boerhaave syndrome, airway compromise and emphysema [13]. Independent predictors for PONV include female gender, young age, non-smoking status, history of motion sickness or past PONV, intraoperative using volatile anaesthetics or nitrous oxide, prolonged duration of anaesthesia and postoperative use of opioids [13, 14]. Considering a multimodal approach can be effective for preventing PONV.
Many varieties of antiemetics could be used for treatment of the PONV as shown in Table 6.3 and Fig. 6.7.
Table 6.3
Classes of commonly used antiemetics
Group | Drug | Adverse effects |
|---|---|---|
1. 5-HT3 receptor antagonists | Ondansetron Dolasetron Palonosetron Tropisetron Granisetron
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