欧洲麻醉后恢复安全与质量管理指南

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Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
Quality and safety guidelines of postanaesthesia care
Working Party on Post Anaesthesia Care (approved by the
European Board and Section of Anaesthesiology,
Union Europe´ enne des Me´ decins Spe´ cialistes)
Laszlo Vimlatia, Fernando Gilsanzb and Zeev Goldikc
Postanaesthesia care units are standard parts of hospital
care in most European Union countries. Their main purpose
is to identify and immediately treat early complications of
surgery or anaesthesia, before they develop into
deleterious problems. This review, prepared by the Working
Party on Post Anaesthesia Care of the European Board of
Anaesthesiology.M European Union of Medical Specialists
(Union Europe´ enne des Me´ decins Spe´ cialistes) and
approved by the European Board and Section of
Anaesthesiology, gives recommendations on relevant
aspects of organization, responsibilities, methods, safety
and quality control of postanaesthesia care. Eur J
Anaesthesiol 26:715–721 Q 2009 European Society of
Anaesthesiology.
European Journal of Anaesthesiology 2009, 26:715–721
Keywords: audit, postanaesthesia care unit, recovery, safety and quality,
standards of care
The areas of expertise of anaesthesiology are perioperative anaesthesia care,
emergency medicine, intensive care medicine, pain medicine and reanimation;
EBA Honorary President, Jannicke Mellin-Olsen, Norway; Vice President, Seppo
Alahuhta, Finland; Honorary Secretary, Ellen O’Sullivan, Ireland).
aDepartment of Anaesthesia and Intensive Care, University of Szeged, Szeged,
Hungary, bHospital Universitario La Paz, Madrid, Spain and cCarmel Medical
Center, Post Anaesthesia Care Unit, Haifa, Israel
Correspondence to Laszlo Vimlati, Department of Anaesthesia and Intensive Care
Medicine, University of Szeged, Semmelweis str. 6, 6725 Szeged, Hungary
E-mail: [email protected]
Received 13 March 2009 Accepted 16 March 2009
1. Purpose of guideline for postanaesthesia care:
To improve postanaesthesia care outcomes for patients who
have just had anaesthesia or obstetric care or sedation or
analgesia care. This is accomplished by evaluating
available evidence and providing recommendations
for patient assessment, monitoring and management
with the goal of optimizing patient safety. It is
expected that each recommendation will be individualized
according to the needs of each patient.
2. Definition of postanaesthesia care:
Activities undertaken to safely manage the patient following
completion of a surgical procedure and the concomitant
primary anaesthetic care, including identification and
immediate treatment of early complications of both
anaesthesia and surgery before they develop into deleterious
consequences.
3. Definition of postanaesthesia care unit:
A unit located as close to operating theatres as possible
in order to avoid unnecessary time loss for transfer of
unstable patients, staffed and equipped for serving for
treatment and care of patients during their immediate
postanaesthesia or post surgery period, regardless of
the type of interventions, before they are scheduled
to be admitted to general wards, other units of the
hospital or discharged home. Postanaesthesia care
units (PACUs) have to be standards in most hospitals
of European countries [1,2].
4. Functions of PACU [1–4]
– immediate postoperative treatment in the PACU,
– preoperative optimization of severely ill patients’
conditions in special situations,
– titration and optimization of acute pain therapy,
– buffer before intensive care unit (ICU), high
dependency unit (HDU) or ward admission,
– evaluation and determination of further treatment
on ICU, HDU or ward,
– improve or optimize patient’s condition for further
treatment at ICU, HDU or ward.
– responsibilities: separated by profession and by
responsibilities although cooperative as well:
– the anaesthetist: during the recovery period, the
patient should still be under the supervision of
the anaesthetist. His or her main tasks during
recovery period:
– monitoring and maintenance of vital functions,
– professional and organizational responsibilities
in the PACU,
– to be present or urgently available immediately
if it seems necessary.
– the surgeon:
– should be notified whenever any possible
surgical complications may require his
intervention,
Guidelines 715
0265-0215  2009 Copyright European Society of Anaesthesiology DOI:10.1097/EJA.0b013e32832bb68f
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
– has to be available for urgent consultation if
it seems necessary.
5. Who runs the PACU? The majority of PACUs in
Europe are run by anaesthesiologists, and the
responsibility for care is also devoted to the
anaesthesiologist [4].
6. Patients admitted to the PACU: exclusively postanaesthesia
or post(peri)operative patients.
7. Transfer from operating room to PACU:
– By suitably trained staff,
– Under the supervision of an anaesthetist,
– Portable monitoring is recommended if alteration
or deterioration of patient’s condition may be
anticipated or the distance of operating room and
PACU makes it reasonable,
– Steps should be taken to protect the patient during
transfer mainly from:
– traumatic injury,
– hypoxia,
– hypothermia,
– soiling of the airway,
– accidental disconnections or removal of drains,
lines, and catheters.
– Properly designed transfer trolleys or beds are
needed [5], equipped with:
– oxygen cylinders, masks, and tubing,
– infusion poles,
– equipment(s) to secure and support airway and
assist ventilation;
– provision of clamps for drainage tubes,
– protective ‘sides’,
– a means to produce head-down tilt.
– Handover: on arrival to the receiving unit [6]
– full and formal handover should take place from
professional to professional,
– with a completed anaesthetic record together
with important details of surgery,
– with specific verbal and written instructions for
postoperative care,
– drugs and fluid regimens must be written on
appropriate charts,
– the anaesthetist should ensure that recovery
staff is taking over the responsibility before
leaving the patient.
– Observation and record keeping: each patient must
be kept under continuous clinical observation
during transport. Physiological parameters should
be measured and recorded at regular intervals.
8. Transfer from PACU to the ward:
– A formal ‘checklist’ is highly recommended
for the staff to satisfy themselves that the
patient is fit to be discharged from recovery area
[7].
– Documentation accompanying the patient should
include instructions for:
– supplemental oxygen,
– fluid therapy,
– analgesic and antiemetic regimens,
– monitoring, if it differs from normal practice of
the receiving unit,
– physiotherapy,
– nursing care provisions.
9. Minimal requirements and recommendations:
9.1. Area, location, capacity and working time [1,4,5]:
– Generally, 12–15m2 per bed as a minimum is
recommended in order to provide undisturbed
access to beds for nursing, therapy and
emergencies. Open areas provide better view
and access to all patients, whereas bays
provide more privacy. Equipments can also
be used more economically in an open area.
– Location: as close to the operating theatres as
possible in order to avoid unnecessary time
loss for transfer of unstable patients if
interventions are necessary. If a hospital
has more separated operating suites, each
suite needs to have its own PACU, staffed
and equipped properly.
– Capacity: generally and on an average, 1.5–2
patients for each operating table but strongly
and inversely dependent on typical duration
of surgery: less if long-lasting procedures are
dominant with slower patient turnover and
more if short procedures or day case surgery
is performed.
– Length of stay: strongly dependent on
dominating type of surgery and capacity of
other wards of the hospital, usually less than
6–12 h but usually no more than 24 h, (but the
last rule may sometimes be overwritten by
special needs).
– Working time: 24 h working time is recommended
but not necessarily. It depends on the
ratio of elective surgery and availability of ICU
orHDU. PACUcan be closed at a certain time,
usuallyduringnight, if surgical schedulemakes
it possible and duties can be taken over
temporarily by other units such as ICUs. In
questionable situations, the responsibility of
decision should concern the anaesthesiologist.
9.2. Equipments and facilities [5,8,9]:
– Bedside monitoring devices at place:
– pulse oxymeter,
– ECG,
– noninvasive blood pressure (BP) monitor.
– Immediately available monitoring devices:
– ECG recording,
– capnograph,
– nerve stimulator,
– means of measuring temperature.
– Specific additional monitoring (e.g. vascular or
intracranial pressures, cardiac output or some
biochemical variables):
– may be required and should be performed
on a case-by-case basis for selected
patients or selected procedures.
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Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
– Mobile monitoring:
– If PACU is not immediately adjacent to
the operating theatre, or if the patient’s
general condition is instable, adequate
‘mobile monitoring’ of above parameters is
needed during transfer.
– It is the anaesthetist’s responsibility to
ensure that transfer is accomplished safely.
– Central monitor station:
– It controls and records all warnings and
alarms of bedside monitors and provides
documentation in the form of hard copies,
and is therefore recommended.
– Facilities needed:
– defibrillator and resuscitation trolley
appropriately supplied,
– difficult airway devices,
– immediate access to blood gas analysis and
acute laboratory testing,
– access to mobile radiograph and ultrasound
imaging and endoscopies,
– warming blankets,
– forced air-warming devices for each bed,
– sufficient air condition system providing a
minimum of 15 air change rate per hour for
sufficient scavenging of anaesthesia gases
and other disinfectant vapours.
9.3. Staffing: dependent on the praxis of individual
hospitals and on the circumstances in which
patients are admitted to the PACU [9,10].
– No fewer than two nurses should be present
when there is a patient in the recovery room.
– There should be an anaesthetist, supernumerary
to requirements in the operating
theatres, immediately available for the recovery
room.
– If it is a local standard to extubate patients in
PACU, practised often for increasing surgical
turnover, one-to-one nursing is necessary
until a well tolerated extubation can be
performed or cardiovascular function stability
achieved.
– The extubation manoeuvre itself is the responsibility
of the anaesthetist!
– If patients are admitted to PACU in awake or
arousable state, nurse–bed ratio may increase
up to 1 : 4, depending on the type of surgery.
– The skill mix of the nursing staff usually
varies, but it is advisable to have specially
trained nurses, including anaesthesia or
intensive care nurses.
– Satisfactory quality of care during recovery
from anaesthesia and surgery relies heavily
on investment in the education and training
of recovery room staff. Maintenance of
standards requires continuous update in
resuscitation skills, application of new techniques,
and advances in pain management.
9.4. Postoperative assessment and monitoring [5,11]
– Patient should be observed continuously by
adequately trained (PACU) nurses and
an anaesthesiologist.
– Respiratory function:
– Oxygen saturation: it is recommended that
monitoring of airway patency, respiratory
rate and continuous oxygen saturation
should be controlled in emergence and
recovery. Particular attention should be
given to monitoring oxygenation and
ventilation.
– Capnography: it is strongly recommended if
patient is ventilated or drug-induced
hypoventilation can be anticipated for
any reasons.
– Cardiovascular function: it is agreed that pulse
rate, BP and ECG monitoring detect cardiovascular
complications, reduce adverse outcomes
and should be done during emergence
and recovery.
 It is recommended that routine monitoring
of pulse rate and BP should be done
during emergence and recovery, and ECG
monitors should be available.
– Neuromuscular function: assessment of neuromuscular
function primarily includes physical
examination. On occasions, it may include
neuromuscular blockade monitor, as it is
suggested to be effective in detecting
neuromuscular dysfunction. It is agreed that
assessment of neuromuscular function identifies
potential complications, reduces adverse
outcomes and should be done during emergence
and recovery.
 It is recommended that assessment of
neuromuscular functions should be performed
during emergence and recovery
for patients who have received nondepolarizing
neuromuscular blocking
agents or who have medical conditions
associated with neuromuscular dysfunction.
– Mental status: assessment of mental status can
detect complications and reduces adverse
outcomes.
 It is recommended to assess mental status
periodically during emergence and recovery.
– Temperature: routine assessment of patient
temperature detects complications and
reduces adverse outcomes.
 It is recommended to assess patient
temperature periodically during emergence
and recovery.
– Pain: routine assessment and monitoring of
pain detects complications and reduces
adverse outcomes.
Guidelines Vimlati et al. 717
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
 It is recommended to assess pain periodically
during emergence and recovery and
manage it accordingly.
– Nausea and vomiting: routine assessment of
nausea and vomiting detects complications
and reduces adverse outcomes.
 It is recommended to assess nausea and
vomiting routinely during emergence
and recovery.
– Hydration status and fluid management: routine
perioperative assessment and monitoring of
patient’s hydration status and fluid management
detects complications, reduces adverse
outcomes and improves patient’s comfort and
satisfaction.
 It is recommended to assess postoperative
hydration status routinely and manage
accordingly during emergence and recovery.
Certain procedures involving significant
loss of blood or fluids may require
additional fluid management.
– Urine output and voiding: assessment and
monitoring of urine output and urinary
voiding detects complications and reduces
adverse outcomes during emergence and
recovery.
 It is recommended that assessment of urine
output and urinary voiding should be done
on a case-by-case basis for selected patients
or selected procedures during emergence
and recovery.
– Drainage and bleeding: assessment and
monitoring of drainage and bleeding detect
complications and reduce adverse outcomes.
 It is recommended that assessment of
drainage and bleeding should be a routine
component of emergence and recovery
care.
9.5. Treatment methods during emergence and
recovery [11]:
– Prophylaxis and treatment of nausea and vomiting:
single or multiple antiemetic agents may
be used for prevention and treatment of
nausea and vomiting.
 It is recommended, when indicated.
– Administration of supplemental oxygen: effective
in preventing and treating hypoxemia, therefore,
 it is recommended for all patients to
administer during transportation or in the
recovery room for patients at risk of
hypoxemia.
– Normalizing patient temperature by active
warming is suggested by the literature to
be effective and the use of forced-air warming
devices is supported. It is suggested that their
use reduces recovery time and shivering and
increases comfort and satisfaction of patients.
Consequently normothermia should be a goal
during emergence and recovery.
 Forced-air warming systems should be
used for treating hypothermia when available.
– Pharmacologic agents for reduction of shivering: it
is cautioned that hypothermia, a common
cause of shivering, should be treated by active
rewarming. Advantages of pharmacologic
agents as additive methods may be considered
for select patients when shivering is
known to be seriously harmful.
 In these patients, meperidine is recommended
as first-line drug for treatment of
shivering during emergence and recovery
for select patients. Other opioids may be
considered if meperidine is contraindicated
or not available.
– Antagonism of benzodiazepines: specific
antagonists should be available whenever
benzodiazepines are administered.
 Flumazenil should not be used routinely,
but may be administered to antagonize
respiratory depression and sedation in
select patients. After pharmacologic
antagonism, patients should be observed
long enough to ensure that cardiorespiratory
depression does not recur.
– Antagonization of opioids: specific antagonists
should be available whenever opioids are
administered.
 Opioid antagonists should not be used
routinely but may be administered to
antagonize respiratory depression in
selected patients. After pharmacologic
antagonism, patients should be observed
long enough to ensure that cardiorespiratory
depression does not recur. It is reminded
that acute antagonism of the effects of
opioids may result in pain, hypertension,
tachycardia or pulmonary oedema.
– Reversal of neuromuscular blockade: T4:T1 ratio
is the single and proven objective measure of
safe neuromuscular function up to now.
 It is recommended that assessment of
restoration of neuromuscular function
(e.g. by train-of-four monitor) should be
checked during emergence and recovery
on a case-by-case basis, and specific antagonists
are recommended to administer for
reversal of residual neuromuscular blockade
whenever indicated.
– Postoperative pain management: anaesthetists
are usually involved in the provision of pain
relief in the days following surgery. If so, they
have to ensure that:
– If patient-controlled anaesthesia systems
are to be used, all staff who are likely to
718 European Journal of Anaesthesiology 2009, Vol 26 No 9
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come into contact with them should have
undergone training in their use and be able
to recognize complications should they
arise.
– The same principles apply to those
required to look after patients receiving
continuous epidural or other regional
blockade.
– Drug prescription charts should be
reviewed and annotated.
– to highlight the administration of neuraxial
opioid infusion
– and help eliminate the risk of unintentional,
simultaneous administration of
opioids by other routes.
10. Special considerations [5]
10.1. Critically ill patients
– Critically ill patients, if being transiently
managed in the recovery area, need special
care:
– The primary responsibility for the patient
lies with the ICU staff.
– All the standards of medical and nursing
care as well as monitoring requirements
should be equal to that within the ICU.
– A special action plan should be worked
out in order to facilitate the transport of
this patient to the ICU as soon as
possible.
10.2 Regional anaesthesia
– The principles of management for any
patient undergoing regional anaesthesia,
either alone or as part of a general
anaesthetic technique, are the same as for
any other patient.
– Information and instructions given on handover
to recovery staff should include:
– site and type of local block,
– drug and dosage used,
– anticipated duration of action,
– instructions for further pain relief and
positional restrictions for the patient.
– Information for the patient includes the
anticipation of return of sensation, motor
function, or both.
– Considerations after spinal and epidural
anaesthesia include noting the level of
analgesia achieved, cardiovascular status,
sitting up (when and how much), bladder
care, details of any continuous infusions,
degree of motor block and time of likely
recovery.
– Many of these considerations also apply to
plexus block.
10.3 Children
– Children have special needs, best met by
having a designated paediatric recovery area
that is child friendly and staffed by nurses
trained in the recovery of paediatric
patients.
– Equipment must include a full range of sizes
of facemasks, breathing systems, airways,
nasal prongs and tracheal tubes.
– Essential monitoring equipment includes a
full range of paediatric noninvasive BP cuffs
and small pulse oximeter probes.
– Children require one-to-one supervision
throughout their recovery room stay.
– Postoperative vomiting, bradycardia and
laryngeal spasm are more common. The
latter can have devastating effects as small
children become hypoxemic much faster
than adults.
– Children should not be denied adequate
pain relief because of fear of side effects. It
can be difficult to assess pain; however,
suitable techniques are available.
– In general, intramuscular injections should
be avoided.
11. Documentation: each patient must be kept under
continuous clinical observation [5,9].
– Data of clinical observations should be
recorded regularly.
– Physiological parameters should be measured and
recorded at regular intervals.
– Drug prescription or medication charts should be
recorded ‘on line’ and annotated.
– Laboratory tests, radiographs or other diagnostics
as well as consultation results should be recorded.
12. Transfer from recovery area to the wards
– A formal checklist should be established to
document that patient is fit to be discharged from
the recovery area safely [5,9,12,13]. It is advisable
that the checklist should include:
– Vital parameters as relevant, such as:
– pulse rate,
– BP,
– arterial O2 saturation,
– train-of-four ratio,
– end-tidal CO2 (mandatory if patient is
ventilated).
– Instructions for the immediate post-PACU
period as required, at least:
– supplemental oxygen,
– fluid replacement,
– analgesic or antiemetic regimens,
– monitoring if different from the normal
practice of the receiving unit,
– physiotherapy,
– others if relevant.
– A formal handover should be performed to a
qualified nurse and documented.
13. Discharge criteria
13.1 Each patient care facility should develop suitable
recovery and discharge criteria based on well defined
principles and should be designed to minimize the risk
Guidelines Vimlati et al. 719
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
of cardiorespiratory or central nervous depression
after discharge [5,7,11,13].
– The requirement of a minimum mandatory stay in
recovery area is a frequent dilemma. The
literature is insufficient to evaluate the
benefits of requiring a minimum mandatory
stay in the recovery area.
 It is recommended that a mandatory
minimum stay should not be required,
but the length of stay should be determined
strictly on a case-by-case basis [11].
13.2 Patients to be discharged to the wards should fulfil
well defined discharge criteria [11], including:
– fully conscious, able to maintain a clear
airway and exhibit effective protective
reflexes;
– respiration and oxygenation are returned to
preoperative base level;
– stable cardiovascular function on acceptable
level with no unexplained irregularity or
uncontrolled bleeding;
– pain and emesis should be properly controlled
and analgesic or antiemetic regime
prescribed;
– use of well defined scoring systems have
proven value on patient safety and quality
control in this respect [5,7,10,12,13];
– if discharge criteria are not achieved, the
patient should remain in the PACU area and
the anaesthetist informed, who anyway must
be available at all times when a patient who
has not reached the criteria for discharge is
present in the recovery room. If there is any
doubt as to whether a patient fulfils the
criteria, or if there has been a problem during
the recovery period, the anaesthetist with
special duties in the recovery room must
assess the patient. Patients who do not fulfil
the discharge criteria may be transferred to
an HDU or ICU but not to normal wards [5].
13.3 Patients to be discharged home
– Patients who are discharged home directly
from the PACU area require special arrangements
to ensure street safety and an
adequate level of after-care [12,14–16].
– Routine use of special scoring systems
[Aldrete, PADSS (postanesthesia discharge
scoring system), etc.] are proven helpful and
therefore recommended.
– Pain and emesis should be properly controlled
and analgesic or antiemetic regime
prescribed [10].
– Further supply of analgesics and antiemetics
as well as handling of other unexpected
events should be advised with particular
attention.
– A signed note outlining any advice given
should be placed in the medical record.
– If discharge criteria are not achieved, the
patient should remain in the recovery room
and the anaesthetist informed.
– If there is any doubt as to whether a patient
fulfils the criteria, or if there has been a
problem during the recovery period, the
patient should remain in the PACU area and
the anaesthetist must be informed and he has
to assess the patient.
14. Quality control
14.1 Audit and critical incident systems should be in
place in all recovery rooms [5,7]. An effective
emergency call system should be in place in all
recovery rooms.
14.2 Monitoring the quality of immediate postoperative
care and audit for compliance with
local and national standards [17] include, for
example:
– recovery room staffing,
– monitoring in recovery room,
– oxygen therapy,
– record keeping,
– discharge protocols,
– postoperative visiting by the anaesthetist,
– critical incidents (there should be a local
system for the documentation of critical
incidents as well as for the response to
them),
– airway problems,
– hypertension and hypotension,
– postoperative nausea and vomiting,
– unplanned admissions to HDU and ICU,
– acute pain management (starts in the PACU
and the quality of pain relief on arrival and
on discharge to the ward should be recorded
and audited),
– education and training of PACU staff.
14.3. Conduct audit for compliance with local
protocols:
– quality of recovery [14,17,18],
– violation of discharge protocol,
– documentation of critical incidents.
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