This section has the following topics:
- Recovery or PACU
- Questions about PACU
- Children in PACU
- Discharge from PACU
- Back on the ward
- Postoperative pain relief
Recovery or PACU
Where you will be
After your operation or procedure, you are taken to one of several places. Most commonly, this is the recovery room (RR) where there are a number of other patients (depending on the size of the facility) also recovering from their anaesthetics. Other names for this area include the Post-Anaesthetic Recovery Room (PARR) or the Post-Anaesthesia Care Unit (PACU).
If you have undergone a very minor procedure, usually not involving an operation, and in a small surgical clinic or X-ray facility, you may be taken to a recovery ‘bay’ or place for a single patient. Your care should be the same as you would receive in a Recovery Room.
If you have only a local anaesthetic or monitored anaesthesia care, you might be discharged directly to the day care ward – for example, after cataract surgery under nerve block. Either your surgeon (in the case of local anaesthesia) or your anaesthetist makes this decision, on the basis of your being stable after the procedure and well recovered from any drugs which you have received.
If you were very ill before surgery, or you had major or complicated surgery (for example, open heart surgery), or complications arose during the course of anaesthesia or surgery, then you might be transferred to an intensive care unit (sometimes known as Intensive Therapy Unit) or high dependency unit. (These units are often referred to by their initials: ICU, ITU or HDU.) They offer a more highly specialised level of nursing and medical care.
When you are transferred to the Recovery Room, your anaesthetist provides the Recovery Room nurse with a brief report. This will include a description of:
- your preoperative condition, including any medical illnesses and medications
- the surgical procedure
- the course of the anaesthetic, including any problems with your airway, any need for airway control in the Recovery Room, and the adequacy of recovery of muscle strength
- intravenous cannulae
- intraoperative fluid balance ( how much intravenous fluid you were given and how much fluid you lost, including blood loss)
- any other important information.
While this description is being given, the nurse usually places an oxygen mask over your face to give you extra oxygen, and attaches a blood pressure cuff and a pulse oximeter. You may or may not be conscious at this stage. If you are not, then you will probably be positioned on your side, which may become a little uncomfortable as you awaken. This position, known as the ‘coma position’, is commonly used in any situation where a person’s ability to protect his or her airway may be weakened. In this position, the tongue falls forward, rather than backwards where it may obstruct breathing. In addition, if the person were to regurgitate or vomit, the vomitus would drain away from the mouth and not be sucked into the lungs.
You may still have a plastic airway or breathing tube in place. Exactly when this tube is removed depends in part on your condition and why the tube was inserted, and also on how conscious you are. Your anaesthetist might choose to remove the tube while you are still in the Operating Room. If you are still deeply unconscious when you arrive in the Recovery Room, your anaesthetist might leave the tube in until you ‘lighten’ or regain consciousness. (The process of removing the tube is known as extubation.) To many people, the thought of having a breathing tube in place while awake sounds unpleasant. However, what anaesthetists consider to be ‘awake’ in the Recovery Room is not quite the same as being fully conscious. In fact, being able to open the eyes and mouth and to take a breath on command are signs that you are probably awake enough to have the tube removed. Most patients do not remember any of this.
Once your anaesthetist is confident that your vital signs are stable and that your safety is assured, the process of ‘transfer of care to the Recovery Room nursing staff’ occurs. This means that the nurses are now responsible for your care and your anaesthetist may leave you to return to the Operating Room to start the anaesthetic for the next patient on the surgical list.
Who will look after you ?
The Recovery Room provides specialised nursing staff that has specific training in the management of common problems of partially anaesthetised patients. Following general anaesthesia, patients in the Recovery Room may develop difficulty breathing. For example, after tonsillectomy, there is always the risk of swelling and bleeding from where the tonsils were removed, making it more difficult for patients to breathe. cardiovascular problems are also of concern. Low blood pressure ( hypotension) can occur because of blood loss or from blood pooling in the veins which dilate as body temperature is restored to normal. High blood pressure ( hypertension) may be due to pain, pre-existing hypertension, and an increased concentration of carbon dioxide in the blood or from having a full bladder. Common but less life-threatening problems include pain, nausea and vomiting. Usually your anaesthetist will leave orders for painkillers or analgesics, drugs to combat nausea and vomiting (anti-emetics), and intravenous fluids. These orders may be written after consultation with your surgeon, but your anaesthetist is the doctor in charge of your care in the Recovery Room.
Questions about PACU
When are you going to start ?
This is the question most often asked by patients when they are regaining consciousness in the recovery room, although the operation is now over. The reason probably lies in the fact that general anaesthesia is really a state of ‘suspended animation’. During this state, many body functions are temporarily changed. One of these functions is that of the ‘clock’ that all of us carry within us. This clock gives us the ability to know that time has passed. For example, when we awaken in the morning from a normal night’s sleep, we usually know that we have slept for some time. With general anaesthesia, this ability to tell that time has passed seems to be temporarily blocked. We are not sure how or why this happens, but the effect seems to last only as long as the state of unconsciousness.
What will I see ?
At first your vision is likely to be somewhat blurred. It is not uncommon to see more than one nurse or anaesthetist, despite the fact that only one is present at your bedside! Gradually you will be able to focus better. Although it is reassuring to be able to see clearly, many hospitals do not recommend that you take your glasses with you to the Operating Room. (This is because of the possibility that they might be mislaid or dropped while you were unconscious.) In that case, you would not be able to wear your glasses until you returned to the ward. Some hospitals do allow you to keep your spectacles with you.
If the hospital allows your relatives to be with you in the Recovery Room, it may be best to leave your spectacles with them. (Some hospitals do not allow any visitors in the Recovery Room.) If your child normally wears glasses, then it is a good idea to have them available, so that the Recovery Room nurse can give them to your child as he or she awakens.
What will I hear ?
In general, your hearing will not be significantly affected, although you may well forget instructions that are given to you during the early recovery period. Some people complain that sounds are louder than normal, but this is usually only temporary and is due to complex interactions between the various anaesthetic drugs and your hearing mechanism. A few patients may develop sudden loss of hearing in one or both ears after an anaesthetic and operation. One reason for this problem is the effect of pressure from the nitrous oxide on the eardrum and Eustachian tube (inside the ear). These patients may complain of pain and / or clicking and popping in the ear, like that which occurs in an aeroplane when climbing or descending. Very rarely, the mechanism of the hearing loss cannot be explained and hearing may or may not recover. However, this complication is extremely rare.
If you normally wear a hearing aid, you may choose to leave it in during the operation. This can be helpful if you have significant hearing loss and are having your operation under regional anaesthesia, when you might need to hear what your anaesthetist is saying to you. Other patients might choose not to wear their aids, especially if they fit loosely and do not provide good hearing. Some patients would prefer not to hear anything that goes on in the Operating Room or the Recovery Room and therefore leave the aids at their bedside.
What will I say ?
You may say all sorts of things, mostly related to your sense of disorientation or your surprise at being awake so soon. You may refer to pain or other discomfort, which can then be treated appropriately. Occasionally, patients say suggestive things to their medical or nursing staff, because the effect of the drugs is to temporarily remove some inhibitions. This is very uncommon, and if it does occur, it is always treated with discretion. This type of reaction lasts only a brief time and patients have no memory of the event. If relatives are present, they should not be concerned.
Will I be in pain ?
Your anaesthetist endeavours to ensure that you are as pain-free as possible at the end of your operation or procedure. This is not always easy to achieve. Some of the anaesthetic drugs provide some pain relief, but need to be stopped at the end of the anaesthetic so that you regain consciousness. A number of techniques are used to control postoperative pain, most being started during the anaesthetic. These techniques can be modified as necessary in the early postoperative phase in the Recovery Room, so that you have the maximum possible comfort. With some conditions, however, complete obliteration of pain may not be possible without risk of complications, especially where control of breathing may be affected.
Will I feel sick ?
You may feel nauseated and it is not uncommon for patients to vomit or ‘dry retch’ once or twice in the Recovery Room. Often this will bring up some mucous or bile-stained fluid, and is usually the only time that vomiting occurs, although some nausea may continue. Your anaesthetist may have given you some anti-emetic drugs during the anaesthetic if vomiting is thought likely to be a problem. Even if an anti-emetic has not already been given, it is not too late to administer some in the Recovery Room, and the nurse will arrange for it to be given.
Will I be cold ?
You may feel cold, and shivering is not uncommon in the Recovery Room. This is due partly to the fact that anaesthesia decreases the body’s ability to maintain a normal temperature, resulting in loss of body heat. Shivering is also due to some of the anaesthetic drugs that ‘switch on’ the shivering mechanism in the recovery phase.
In recent years, much more attention has been paid to ensuring preservation of body heat during surgery so that postoperative shivering is now less common. Devices such as warm water mattresses, warm air blankets, insulation wraps, and warmers for intravenous fluids and anaesthetic gases have contributed to this improvement.
Children in the PACU
Children often go through a period of disorientation and restlessness which may be difficult to manage for a short time as they regain consciousness. This affects younger children more frequently and is quite normal, although rather distressing to parents or guardians. The reaction is more common after short procedures where there is minimal use of potent painkillers or other sedatives. The restlessness may be prevented or treated by the use of sedatives, either at the time or given as premedication. However, the effect of any of these drugs is to prolong recovery time significantly. If this type of distress has been a concern on previous occasions or with siblings, you should discuss the management with your child’s anaesthetist.
Children are frequently able to drink while still in the recovery room. Usually babies can be breast-fed, unless there is some particular reason to not do so.
In most modern surgical suites it is usual to allow parents to sit with their children as they awaken from anaesthesia. You may be encouraged to do so, once the nurse caring for your child is satisfied that all vital signs are stable and recovery is proceeding normally. You should ask your hospital or anaesthetist as to whether or not they allow this practice.
Some young children do not wake easily after an anaesthetic, especially if the anaesthetic coincides with the child’s normal sleep pattern. This is more likely if the recovery phase coincides with the child’s usual bedtime and if the child is normally a heavy sleeper. The situation may be quite disturbing to parents, but is quite normal. The use of painful stimulation to ‘wake the child up’ is discouraged.
Discharge from PACU
Anaesthetists and nurses use specific criteria to determine if a patient is fit enough to be discharged from the recovery room. A patient must:
- be able to breathe properly without assistance
- have stable vital signs (for example, blood pressure and heart rate)
- be awake (except children, see separate section) and orientated
If there is any bleeding from the surgical site, it should be well controlled and minimal.
In general, when a patient meets all these criteria, the nurse may discharge the patient from the Recovery Room without the anaesthetist being present. However, some patients require review by their anaesthetist, even if they meet the discharge criteria. Other patients might not meet the criteria, despite having spent what appears to be an appropriate length of time in the Recovery Room. This might be because of complications from the operation or anaesthetic, or from problems with pre-existing conditions. These patients might require further consultation (e.g. by a cardiologist or referral to an HDC or ICU).
The nurses are responsible for maintaining a record of the patient’s condition in the Recovery Room. They are also responsible for conveying relevant information to the ward, unit or clinic to which the patient is to be transferred. Depending on the operation, most patients stay for a minimum of 30 minutes in the Recovery Room, although this time may be increased to a few hours if the patient has undergone a very complex operation. Occasionally patients may have to stay longer in the Recovery Room, although they are ready for discharge because of administrative problems within the hospital, such as a lack of nurses or porters to transport the patient, or a lack of beds on the ward.
Back on the ward
After discharge from the recovery room, you are transported to a ward. This may be a regular ward, where you will spend at least one night. The length of time spend in the hospital ward varies according to the severity and length of your operation, and to a certain extent the complexity of anaesthesia.
Alternatively, you may be taken to a day ward, where you spend only a few hours before going home. Many procedures (up to 70 per cent in some countries) are now performed on a day-stay basis, with the patient staying in the hospital or clinic for less than 24 hours. Not all procedures are suitable for discharge home so soon, especially major operations involving surgery on the brain, or within the chest or abdominal cavities, or surgery requiring continuous intravenous or epidural pain relief, such as after total hip replacement.
No matter how long you stay, the nurses will ensure that you are continuing to follow the expected course of recovery from your anaesthetic and operation.
Postoperative pain relief
The management of postoperative pain is a continuation of the pain control provided during your anaesthetic. Both your anaesthetist and your surgeon may be involved in prescribing the drugs used for relieving your pain.
There are several options for postoperative pain control, which can be distinguished by the route or manner by which these drugs are given. These options include the following.
Oral or rectal analgesics and anti-inflammatory drugs
These drugs include paracetamol or acetaminophen (alone and with codeine), codeine phosphate, anileridine, tramadol, buprenorphine, indomethacin, and ketorolac. Most of them are taken as tablets, although a syrup may be used for children. Many of these drugs may also be given as suppositories. They are used for mild to moderate pain and are suitable for patients who are staying in hospital after minor operations or who are to be discharged home the day of the operation. These drugs have few common side effects, apart from constipation with codeine and the risk of reduced breathing if an overdose of anileridine is taken. There have been a few rare cases of sudden onset of kidney failure in patients who have been given ketorolac, although the evidence proving such a link is not clear.
Most often this route is used for the administration of opiate or narcotic analgesics. These are given on an intermittent basis, usually every few hours. A typical order would be ‘ morphine 10 mg im q4h prn’ (which translates to ‘give 10 mg of morphine intramuscularly every four hours – but no sooner – if the patient wishes it’). This technique provides adequate, but not very good, pain control. Shortly after receiving the injection, the patient gets the effect of a large amount of drug, which may reduce breathing and produce sedation and even confusion. Then the effect of the drug wears off, leaving the patient in pain until the next injection. The use of intramuscular injections is declining in popularity, not only because continuous administration methods provide better pain control, but also because of the discomfort of the injection.
Continuous intravenous infusion
With this technique, opiates or narcotics are delivered directly via an intravenous cannula at a predetermined rate. This provides a steady concentration of drug in the bloodstream (in contrast to the intramuscular technique which gives a variable blood concentration). Nursing or medical staff may adjust the rate of infusion, according to the pain relief obtained.
Continuous subcutaneous infusion of analgesics
This is similar to the intravenous method, except that the fluid is pumped through a fine needle into the tissues just under the skin, usually on the abdomen. Because the volume of fluid is small, there is little swelling or discomfort and the drug is well absorbed.
Patient controlled analgesia (PCA)
This is another method of intravenous injection of opiates or narcotics, except that the patient controls the analgesia by pushing a button to determine when the injection is given. The administration of the drug is determined by a pump that has been programmed to deliver a fixed, safe dose of drug every time the patient requests it. There is a maximum hourly dose and a ‘lock-out’ interval that can be adjusted to prevent overdose. (This is similar to bank machines, which have limits on withdrawals.)
This technique is based on the principle that if the patient who has become sleepy will not push the button until the effect of the drug wears off. Of course, this principle requires that only the patient, and not a friend or family member, pushes the PCA button. Often anaesthetists are in charge of programming these pumps, although surgeons or specially trained nurses may also do so. If necessary, the dose and timing of the drug may be adjusted by reprogramming. Drugs commonly administered by this method include morphine, pethidine ( meperidine), and fentanyl. Some doctors also prescribe a constant infusion (or a ‘background infusion’) of a small amount of drug, so that there is always some pain relief present. However, this technique carries a greater risk of reduction of breathing, than does the ‘demand’ technique alone, although it is useful in certain patients with extreme pain.
Spinal narcotic injection
Some anaesthetists like to add a small amount of an opiate or narcotic when they inject local anaesthetic into the spinal at the time of the operation. This can provide very good pain relief. For example, a woman having a caesarean section might not need any other pain medication after the operation if she has received some spinal (‘intrathecal’) opiate or narcotic.
Spinal or epidural infusions
Continuous infusions of local anaesthetics and/or narcotic analgesics into the spinal fluid or epidural space may be given for several days after surgery. The advantage with this technique is that there is little sedation, compared with other methods. These methods are particularly useful for patients undergoing chest operations (thoracotomies) or upper abdominal operations, or major orthopaedic surgery to the hips and legs. These operations are painful and most patients require large amounts of intramuscular opiates or narcotics to provide adequate pain relief, with the possible risk of reduced breathing. The use of an epidural or spinal means that the patient can actually be pain-free.
In addition to general anaesthesia, some anaesthetists like to perform a nerve block – to provide analgesia (pain relief) of the area in which the operation or procedure is to take place. This is commonly done for children undergoing circumcision (with a penile nerve block) or hernia repair (with a caudal anaesthetic). Some anaesthetists believe that blocking pain nerves before the patient has any pain actually decreases the amount of pain relief required. This is termed ‘pre-emptive analgesia’.
Two other important points must be made about pain management. The first is the role of the acute pain Service (APS). In the 1970s, researchers began to investigate different methods for the relief of postoperative pain. Then in the 1980s, anaesthetists started to apply this knowledge to improve pain relief. These methods included all those described above. Use of these different techniques has varied widely between institutions; however, most large anaesthetic departments provide a postoperative analgesia service (or Acute Pain Service). Successful programmes rely on the assistance of dedicated, specially trained nursing support.
The other important point about pain management is that all patients who receive opiates or narcotics are at risk of reduced breathing. Some patients need to be looked after in special care units, not only because of the narcotics but for other medical or surgical reasons. Other patients require frequent monitoring, but can be cared for with regular nursing.
Questions about postoperative pain relief
How bad is your pain ?
Regular assessment is made of your pain after surgery, but you should tell your treating doctors and nurses if your pain is not controlled. In many hospitals, a scoring system is used to assess the effectiveness of pain treatment. The scoring system usually asks you to score the severity of pain on a scale of zero to ten, with zero being no pain and ten being unbearable pain.
Are you likely to become addicted to opiates or narcotics ?
No, the administration of these potent drugs after surgery, to provide relief of surgical pain, does not lead to addiction even when large doses are required.
Are there other methods of pain relief ?
There are other methods of pain relief that do not involve the administration of drugs. These ‘non-pharmacological’ methods include:
- Application of warmth: Heated gel or beanbag pads may be used, as may infrared lamps. Great care must be taken to avoid burning the skin, especially in the elderly and those with fragile skin or poor circulation. Lamps, in particular, should only be used for a short time.
- Distraction: This is a method of pain relief which is useful in patients of all ages, but particularly in children. The idea is to concentrate the mind on something other than the pain. This can be done by reading, doing puzzles, story-telling, looking out a window at a busy street, and even watching television.
- Relaxation: Three ways of relaxing and reducing the psychological awareness of pain are listening to music, meditating, and having a massage.