FUNDAMENTAL PRINCIPLES
Patient recovery and the
post-anaesthesia care unit
(PACU)
Nick Preston
Maggie Gregory
Abstract
Patient recovery is the time from the end of anaesthesia/surgery to regain-
ing full control of airway reflexes. During recovery immediate postopera-
tive complications may arise. Major complications arise in 3e17% of
inpatient surgical procedures. These complications should be managed
either in theatre or in a designated recovery area (post-anaesthesia
care unit).
Keywords PACU; post-anaesthesia care unit; postoperative care;
recovery
Royal College of Anaesthetists CPD Matrix: 1C01, 1C02, 1D02, 1H01,
1H02, 1I02
Definitions
 Patient recovery e defined as the time from the end of
anaesthesia/surgery to regaining full control of airway
reflexes. It includes the management of immediate post-
operative complications (pain, nausea, airway obstruction,
vomiting etc). The patient then being in a stable condition
can be transferred to an area with reduced staffing such as
a ward (i.e. not necessarily needing one-to-one nursing
care). Alternatively the patient may be transferred to
another high-care area such as the intensive care unit,
where similar care can be maintained for longer periods.
 Post-anaesthesia care unit (PACU)/recovery e area
immediately close to theatre, with staff, equipment and
facilities to manage postoperative patients and complica-
tions following surgery.
What is a recovery area/PACU?
A PACU should be a large area with the capacity to manage a
greater number of patients than can be operated on at any one
time. There are specifications for size, temperature, humidity, air
changes and scavenging to be found in Association of Anaes-
thetists of Great Britain and Ireland (AAGBI) documentation1 and
Health Building Note 26.2 The precise size will depend on the
length of each operation and the period of recovery needed. Most
patients should normally transit PACU in less than 1 hour. A
Nick Preston BSc (Hons) MBBS FRCA is an ST7 Anaesthetist at North Bristol
NHS Trust, UK. Conflicts of interest: none declared.
Maggie Gregory MB ChB FRCA is an Anaesthetic Consultant at North
Bristol NHS Trust, UK. Conflicts of interest: none declared.
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
Please cite this article in press as: Preston N, Gregory M, Patient recovery and the post-anaesthesia care unit (PACU), Anaesthesia and intensive
care medicine (2015), http://dx.doi.org/10.1016/j.mpaic.2015.06.015
Learning objectives
After reading this article you should be able to:
C
C
define what is meant by patient recovery
list the equipment that needs to be available in a post-
anaesthesia care unit (PACU)
C define discharge criteria from recovery
C understand a different model of recovery/PACU
C define Association of Anaesthetists of Great Britain and Ireland
minimum standards of monitoring
theatre may output patients faster than they can transit PACU
postoperatively e therefore PACU needs to be able to handle
multiple patients from each theatre. This situation is especially
important for day-case anaesthesia, since the fast turnover of
patients will place significant pressure on PACU. It is crucial to
effectively plan theatre lists for the resources available otherwise
any backlog in PACU may hold-up theatres. Close liaison be-
tween each theatre and the PACU will facilitate good patient
throughput with efficient theatre utilization. The patient in re-
covery will remain the responsibility of the handing over clini-
cian (usually the anaesthetist), until the patient leaves the PACU.
Staffing
The PACU needs appropriately trained staff, who are capable of
managing airways and postoperative complications. Staffing re-
quirements will depend on the patient population, but all pa-
tients should be nursed individually. There will also need to be a
number of floating staff to enable flexibility and management of
emergencies without compromising other individual patients,
during such an event. There should also be a named person in
charge of the recovery area to liaise and coordinate the flow of
patients in the recovery area.
Audit
There should be regular audits covering the management of pa-
tients, patient performance of the PACU and patient satisfaction.
This serves to ensure that healthcare is delivered in the right
way, and contributes to the feedback available for training of
staff in recovery and in theatre service improvement.
Regular team training should take place which should include
management of emergencies in theatre/PACU. All team members
should take part. For example an exercise could be provided by
doing a simulated event in one theatre using a dummy patient.
Although this would at first seem to detract from operating time,
it provides a mechanism to ensure safe, whole team training in a
real environment.
Why do we need a PACU?
Following anaesthesia (which may be general or regional)
patients should be transferred from theatre to a recovery area.
Patient recovery may be divided into two stages e Stage 1:
immediately following surgery, where they may be physiolog-
ically unstable or have the potential to become so. This re-
quires one-to-one nursing. Stage 2: where the patient is fit
1 2015 Elsevier Ltd. All rights reserved.
 FUNDAMENTAL PRINCIPLES
enough to return to the ward. The purpose of the PACU is to
allow the patient sufficient time to regain full control of airway
reflexes, for any immediate postoperative complications such
as nausea/vomiting, airway obstruction and analgesia to be
managed, and to ensure that patients remain physiologically
stable. Immediately following an operation, patients remain at
high risk of critical events (Stage 1 recovery), but with good
monitoring and vigilance, most events can be treated early.
Major complications occur in 3e17% of inpatient surgical
procedures1 and require some treatment after anaesthesia.
Centralizing recovery skills into a single area enables good risk
management of these cases. After PACU discharge criteria are
met, the patient may be transferred back the ward or other
discharge area.
AAGBI guidelines for recovery area
AAGBI minimum standards of monitoring3 should still apply to
the PACU. Namely clinical observations supplemented by:
 pulse oximetry
 non-invasive blood pressure.
In addition there should be immediate availability of the
following:
 electrocardiography
 nerve stimulator
 temperature measurement
 capnography
 mobile monitoring equipment for transferring unstable
patients
 invasive pressure monitoring capability (arterial, central
venous pressure, intracranial etc).
Information for handover of patients to/from the PACU
This information should be documented, but also pertinent
points raised verbally on handover to recovery staff and then to
any further ward staff as needed:
 surgical procedure (i.e. craniotomy)
 anaesthetic technique (i.e. endotracheal intubation)
 lines (i.e. intravenous, arterial and central venous pressure
lines)
 past medical history, allergies and pre-morbid state
 airway e devices utilized/airway manoeuvres required
 breathing e rate, depth, ventilatory parameters if
ventilated
 circulation e cardiovascular stability, preoperative blood
pressure, heart rate, rhythm
 analgesic plan e preoperative pain, perioperative tech-
niques and postoperative instructions
 other e drains, additional monitoring (i.e. free flaps
needed for chest X-ray etc).
Integrating services
In the current political and economic climate all areas of
healthcare are facing significant challenges to become more dy-
namic and offer the highest value-for-money. PACUs can also
have additional functions if they are of sufficient size. For
example, patients may be brought there to holding bays to reduce
ward transit times, ensuring theatre lists are used efficiently. It is
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
Please cite this article in press as: Preston N, Gregory M, Patient recovery and the post-anaesthesia care unit (PACU), Anaesthesia and intensive
care medicine (2015), http://dx.doi.org/10.1016/j.mpaic.2015.06.015
also possible to place regional anaesthetic block patients in the
PACU whilst waiting for the block to fully establish, in the
meantime completing a short case in theatre. This allows the
recovery area to be useful both pre- and post-theatre, utilizing the
precious and traditionally under-utilized hospital space espe-
cially at the start of the working day.
During times of exceptional capacity short-stay high-de-
pendency unit (HDU) patients may be accommodated in the
PACU if resources allow. This should be seen as an emergency
measure since these complex patients require intensive nursing
and medical care and therefore the appropriate resources need to
be put in place to be able to support such abilities. This includes
training, staffing and equipment e if this is not done effectively
then there will be a significant impact on the theatre throughput
and consequently on patient care.
Other hospital services such as preoperative assessment and
cardio-pulmonary exercise testing also provide value in pre-
operative planning and allow risk stratification of patients. This
lessens any foreseeable impact on both the patients recovery
and on the PACU.
Distributed recovery/PACU
In the quest for better patient care, innovative alternatives to
traditional working practices are being developed, one of these
concepts is the medi-room. The idea behind such rooms is for
the patient to be admitted from a reception area directly into a
medi-room, where the patient can change, be seen by the
admitting practitioner, anaesthetist and surgeon. The patient will
then travel directly to theatre when called for, have their oper-
ation and then return directly from theatre to the medi-room. The
recovery staff would stay with the patient in the medi-room until
the immediate patient recovery is complete. The patient would
then either be discharged home or be transferred to a ward. The
medi-rooms would still need to be situated immediately near to
theatres for anaesthetic cover. The advantages of such a
distributed recovery model include:
 patient privacy/dignity
 patient satisfaction
 better infection control as individual rooms
 cannulation/simple lines could be placed before travelling
to theatre
 less patient transit throughout the hospital, as direct
discharge of day-case patients.
The disadvantages of a distributed model include:
 higher recovery staff numbers required
 assumes a rapid discharge possible from medi-rooms
 capacity dependent on accurate modelling
 reduced ability to deal with unforeseen peaks in workload
 challenges traditional clinical model.
Daily checks/equipment
This list is by no means definitive and each unit will be able to
add to this, based on local preferences and needs. Each day the
recovery area should be checked to confirm:
 resuscitation equipment and trolleys stocked
 drug cupboards stocked
 oxygen supply and delivery system
 suction
2 2015 Elsevier Ltd. All rights reserved.
 FUNDAMENTAL PRINCIPLES
 airway trolleys stocked and basic equipment available at
each bed space (i.e. Guedel airways etc)
 breathing circuits
 monitoring (blood pressure/oxygen saturation/electrocar-
diogram/respiratory rate)
 intravenous drip stands
 blankets/forced air warming facilities
 sharps and waste bins (clinical and non-clinical)
 telephones
 blood collection system available
 IT system
 availability of trained recovery staff
 range of dressings/drains available
 access to sluice area
 alarm system to summon help in an emergency.
Discharge criteria for the PACU
Discharge criteria must be defined for the PACU, and if a patient
fails to meet these criteria then recovery staff should seek advice
from the anaesthetist regarding consideration for referral
admission to a high-care area (i.e. HDU).
Standard discharge criteria include:
 conscious level: rousable to voice, orientated to near pre-
operative level
 airway: able to cough (i.e. return of full airway reflexes), a
clear airway
 breathing: respiratory rate over 8, under 16 (adult popu-
lation), adequate depth, not obstructed, well oxygenated
 circulation: stable cardio-pulmonary rate/rhythm within
acceptable limits, no ongoing unstable blood loss
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
Please cite this article in press as: Preston N, Gregory M, Patient recovery and the post-anaesthesia care unit (PACU), Anaesthesia and intensive
care medicine (2015), http://dx.doi.org/10.1016/j.mpaic.2015.06.015
 pain/emesis: controlled
 documentation: analgesic, fluid and anti-emetic regimens
prescribed, theatre documentation complete and relevant
handover documentation completed e either physically or
electronically
 temperature: over 36 C, under 38 C
 discharge location: safe and appropriate area to which
patient can be transferred.
Further criteria can be added to the list based on patient type
(e.g. monitoring of skin-graft sites etc) and on the individual patient
and procedure. Criteria should be primarily the responsibility of the
anaesthetist, although evidence such as the World Health Organi-
zation Surgical Safety checklist4 demonstrate that the entire oper-
ative team should have input into the process. Therefore if there are
concerns regarding drains/dressing etc then this should be
included in the handover to recovery and the ongoing ward staff.A
REFERENCES
1 Immediate post-anaesthetic recovery. September 2002. The Associa-
tion of Anaesthetists of Great Britain and Ireland, http://www.aagbi.
org/sites/default/files/postanaes02.pdf.
2 Health Building Note 26. London: Operating Department, HMSO, 1991.
3 AAGBI recommendations for standards of monitoring during anaes-
thesia and recovery. 4th edn March 2007.
4 World Health Organization. Safe surgery saves lives. www.who.int/
patientsafety/safesurgery/en/, Last accessed May 2012.
FURTHER READING
Allman KG, Wilson IH. Oxford textbook of anaesthesia. 3rd edn. OUP
Oxford, 2011.
3 2015 Elsevier Ltd. All rights reserved.