Care of the Intensive Care Unit Patient in the PACU

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55: Care of the Intensive Care Unit Patient in the PACU

Myrna Eileen Mamaril


burn care; critical care; family visitation during resuscitation intensive care unit (ICU); neurosurgery; pathogenesis of COVID-19; postanesthesia care unit (PACU); sepsis

The nursing care in the postanesthesia care unit (PACU) continues to evolve from a discrete specialty of postanesthesia patients to one that is more broadly defined by the critical care patient population these PACU nurses serve. Their expanded role is challenged by the rapid resuscitation and the intensive supportive care these critically ill patients may require. The PACU serves as a patient care unit where frequent critical assessments and monitoring of trends in the patients’ physiologic parameters provides the standard of care. Today, intensive care unit (ICU) patients are now part of the ever-changing landscape of PACUs.17 The frequency of caring for this population has been magnified by the critical care shortage of ICU beds due to the extended length of stay of COVID-19 patients in the ICU. Consequently, the delayed throughput of these surgical ICU patients results in not only overflow but also possible long-term boarding of this population.2 The terminology of overflow and boarding refers to this unique critical care patient population who not only recover in the PACU but subsequently may also remain in the PACU and be transferred the next day to an inpatient bed or even discharged home, avoiding being transferred to a premium ICU bed. Other influencing, competing factors are the increasing acuity of both the emergency department (ED) patients and deteriorating status of inpatients that places greater demands for ICU admissions. This increase reflects an ever-growing nationwide health care dilemma for EDs, inpatients, and PACUs whose intensive care needs create a high demand for critical care beds.17

The challenge of managing ICU patients in the PACU is also identified as an international PACU nursing concern.46 During the COVID-19 pandemic, global hospital administrators and senior nursing leaders looked to solve their hospitals’ surge capacity by expanding their PACUs to become the new COVID ICUs in order to meet critical challenges in caring for the increasing number of intubated patients who experienced acute respiratory distress syndrome (ARDS) requiring mechanical ventilation.6,7 When ventilators became scarce, anesthesia gas machines were then retrofitted as ventilators while certified registered nurse anesthetists were called on to manage these high-tech machines in the PACUs.6,7

As the science of perianesthesia nursing has evolved and become increasingly more sophisticated, nursing educators, managers, and administrators have realized the importance of an economically sound evidence-based practice (EBP) that continuously strives to provide safe quality care to the ICU patient in the PACU. However, recovery of the critically ill postoperative patient in the PACU often poses a myriad of challenges to the postanesthesia nurse and the PACU.25

Throughout the United States, divergent postanesthesia practices have existed in the provision of care for the ICU patient undergoing surgical or invasive procedures. Operationally, ICU recovery must occur on a routine basis regardless of prognosis or acuity in the appropriate care setting. Care of the ICU patient in the PACU may not be a daily occurrence in some PACUs, making this care sporadic or an exception to the norm. From a clinical and an administrative position, however, the PACU must provide the optimal standard of care to these ICU patients.

This chapter discusses the historical significance of critical care recovery, administrative issues in extended ICU care, innovative educational opportunities to ensure competent staff, and clinical strategies in caring for complex, high-acuity, critically ill patients. Because patient safety is essential in providing care to low-volume high-risk patients, complex and highly specialized ICU nursing care will focus on neurosurgical, burn, sepsis, and the specialized COVID-19 management that occurs in the PACU. Ultimately, postanesthesia care must be focused on providing competent, high-tech, and vigilant care while keeping critically ill patients safe. Finally, when the ICU patient’s condition becomes life-threatening, family presence during resuscitation is essential as a nursing intervention that promotes patient–family-centered care.


Cytokine Storm Excessive production of proinflammatory cytokines leads to ARDS aggravation and widespread tissue damage resulting in multiorgan failure and death from COVID-19. Targeting cytokines during the management of COVID-19 patients could improve survival rates and reduce mortality.

Extended-Stay ICU Patients Critically ill surgical patients who have recovered from anesthesia but need to stay in the PACU for an extended or prolonged period of time because of the severity of illness or the need to be observed for complications.

Family Presence Families are provided the opportunity to be present in the PACU with their loved one during life-threatening situations, procedures, and/or at the end of life during cardiopulmonary resuscitation or codes.

Intensive Care Unit (ICU) A hospital setting where critically ill patients are provided nursing care. This care may also include the surgical ICU setting where critically ill surgical or invasive procedural patients need specialized postoperative monitoring.

Intensive Care Unit Boarders Critically ill surgical patients who have recovered from anesthesia in the PACU. These patients have been designated ICU status but do not have an ICU bed and are boarding in the PACU.

Intensive Care Unit Overflow Patients Patients who have undergone anesthesia for surgical procedures, have recovered in the PACU and are awaiting transfer to the ICU.

Sepsis A systemic response to infection.

Septic Shock Sepsis that progresses to a state of inadequate tissue perfusion characterized by persistent hypotension despite adequate fluid resuscitation.

Systemic Inflammatory Response Syndrome (SIRS) A systemic inflammatory response to insult or possible infection that involves the activation of the inflammatory system and results in changes in body temperature, elevated heart rate, respiratory rate, and white blood cell count.

Historical significance of critical care recovery

During the late 1950s and early 1960s, ICUs emerged in hospitals for close monitoring of critically ill patients. Before that time, critically ill postsurgical patients received care in recovery rooms and inpatient wards. Critical care nursing was conceived to provide a setting in which the most acutely ill and injured patients received concentrated nursing care to enhance survival.8

Today, the design of the ICU is focused on individual rooms to promote healing with a concentration on noise reduction from physiologic alarms as well as bioengineered for proper airflow and a biological containment environment. Many ICU rooms are designed to accommodate family visitation and provide comfort measures such as music and interactive technology. The ICU provides patient privacy and is focused on highly technical care that can also be family centered with a liberal visiting policy. Likewise, the American Society of PeriAnesthesia Nurses (ASPAN) advocates for family visitation in PACU Phase I.9 In comparison, the interior design of the PACU is changing from one large room in which individual patient units are separated by curtains to individual rooms with walls. Like the ICU environment, PACU bays may include specialized lighting, noise reduction curtains, sound-absorbing ceiling tiles, visitor sleep chairs, televisions with interactive technology, and even private toileting.

Administrative issues

Financial Constraints

The 1990s brought increased financial constraints on hospitals and increased competitiveness among hospitals. The focus in the 1990s on controlling costs led to a dramatic shift in the types of patients who were admitted to hospitals.1013 Only the sickest patients were eligible for admission, and the length of stay was compressed to the shortest possible time. Although hospital population dropped, ICU patient volumes steadily increased. Hospital mergers and closings occurred in many cities. During this same time, two significant changes developed: (1) patient acuity of critically ill patients admitted to hospitals increased, and (2) the shortage of ICU nurses prompted hospital administrators to close ICU beds. The lost surgical and anesthesia revenue threatened the viability of the hospital if surgical cases continued to be delayed or canceled. ICU bed closures had a serious effect on PACUs. PACUs were naturally chosen for critical care overflow because the environment of care included highly technical monitoring and many critical care–educated nursing staff. In addition, the retention of staff in the PACU was much higher with fewer vacancies. This choice seemed to be the ideal answer to a complex problem. Consequently, the PACUs were increasingly requested for recovery of ICU patients, and many hospitals designated the PACUs as an ICU overflow unit until an ICU bed became available.

Management Dilemmas

Nurse managers encounter numerous challenges among competing health care providers that relate to patient placement priority for ICU beds. These challenges are affected by the decisions of senior administrators (e.g., chief operating officers, chief nursing officers, departmental medical officers of medicine and surgery, and emergency or trauma physicians). The dilemmas faced by managers affect patients, families, ancillary staff, and the PACU staff nurses. The PACU manager is obligated to follow hospital policies and protocols. When senior administrators make decisions in the best interest of the hospital to keep the EDs and operating rooms (ORs) open and to perform surgery for elective surgical cases regardless of high occupancy, the PACU becomes the relief valve for medical center admissions during times of high census. Often, the hospitalized patients who occupy beds in the ICU are not ready for transfer to a lower level of care. This gridlock has a domino effect on the PACU beds. ED patients who need critical care may be given priority status for ICU beds as well as “post-arrest” and “rapid response team” (RRT) patients from inpatient units. Some ICUs actually hold beds open for potential arrest situations. As the inpatient and ICU surgical cases are completed, they too compete for the PACU available beds. PACU bed availability is also affected if the PACU is still holding ICU patients from the day before or from earlier in the morning. Eventually, the OR schedule may grind to a halt because of the ensuing gridlock of beds. In some hospitals, the OR continues to perform surgery on critical care patients with admission of more ICU overflow patients to an already stressed PACU. These ICU patients become known as boarders, extended stay, or ICU overflow. Patients and families may voice intense dissatisfaction when the PACU is designated for ICU care.

Recovery of the ICU patient who has an extended stay in the PACU may have serious physician repercussions. Anesthesia providers and surgeons become frustrated because they want to complete the elective surgical schedule. Continued delay or cancellation of cases could result in physicians’ refusal to schedule their cases at certain hospitals. At times, behaviors may strain relationships with the staff, charge nurses, and the nurse manager. University hospitals also have graduate medical education residency programs, and residents need to perform a required number of surgical or anesthesia cases per year to qualify for accreditation.

Other challenges encountered by medical staff may place the ICU patient’s care at risk. Medical management of the ICU patients by the medical intensivist may be delayed because of the physical location of the PACU or other work demands or coverage commitments to critical care patients in the hospital’s designated ICU.14 Confusion of PACU nursing staff may exist regarding whom to contact for medical or surgical problems that arise, especially on nights, weekends, or holidays when resources are stretched to capacity. Another issue that frequently surfaces is the need to have medical consultations.15 PACU staff may believe that lack of timely medical care not only increases the stress of the nurse but also ethically affects the professional duty to provide safe, timely, quality care. Further delays in treatments can critically affect a patient’s condition. Finally, the surgeon may become upset with the hospital administration because the order was for the ICU patient to be admitted to the ICU for postoperative care and management.

The physical location of the PACU is always adjacent to the OR; however, the ICU may actually be in a different area of the hospital. This situation can create delays in diagnostic care or treatment that otherwise is more expeditious if the patient is in the ICU.14,15 For example, respiratory therapy/pulmonary services, blood bank, and the critical care laboratories may actually be located in the ICU. Advanced practice nurses and physician assistants assigned to the ICU may not be available for ICU patients in the PACU. The PACU may have to wait for the hospital’s respiratory therapist or laboratory technician to come to the unit. If a computed tomographic scan or magnetic resonance imaging scan is needed, the PACU nurse might not be able to transport the ICU patient in a timely manner because of assigned care of another postanesthesia patient. The ICU patient may need specialized treatments, medications, or vasoactive intravenous drips that are not immediately available to the PACU nurse. Ancillary services have a vital role in the care and management of the ICU patient that may not be immediately available in the PACU.

ICU patients emerging from anesthetic agents frequently request that their families visit in the PACU. Traditionally, PACUs have been considered a large open unit in which family visitation is severely limited because of other patients recovering from anesthesia. This type of policy can create intense conflict between the nurse and the family. Family expectations of a private room in which families can visit freely are not met. Furthermore, the family’s anxiety increases when the surgeon speaks about the critical nature of the surgery and the need to place the patient in the ICU. Families frequently worry and may perceive the ICU as a sign of impending death based on past experiences or those of others.16 Understanding what “critical care” or “ICU” means to patients and families helps the nurse promote positive coping skills. Depending on the patient’s physical condition, effective communication with the ICU patient may be challenging. Barriers to communication can relate to emergence from anesthesia, the patient’s physical status, the existence of endotracheal tubes that inhibit verbal communication, medications, or other conditions that alter cognitive function.16,17 The critical care patient’s anxiety can increase the stress response and further complicate the patient’s recovery. Patients may consider that they have a right to see and visit with their family and may rely on significant emotional support for well-being from their family’s engagement.16

Managing and communicating with the ICU families in the PACU can be challenging. Depending on each patient’s diagnosis and acuity, the ICU patient’s family may be in crisis. If the patient’s condition is critical, the family may exhibit a high degree of stress, anxiety, blame, or other disturbing behaviors. Families may be emotional and act out or exhibit disruptive outbursts. The staff nurse may believe that one’s first duty is to provide care to the patient and not to the family. Time can pass quickly for the PACU nurse and not afford the timely family visits. Anxiety and worry mount for the waiting family as a result of little or no communication and fear of the unknown. The PACU nurse needs to make a conscious effort to effectively communicate with the family in a manner that promotes coping, personal growth, and adaptation to the ICU patient’s critical condition (Box 55.1).7,17,18 PACUs have recognized the value of family communication, and many are advocating for the role of the perianesthesia nurse liaison.

Box 55.1

PACU Nursing Actions for Families in Crisis

PACU, Postanesthesia care unit; SICU, surgical intensive care unit.

Adapted from Norton C. The family’s experience with critical illness. In: Morton PG, Fontaine DK, editors. Critical care nursing: a holistic approach. 10th ed. Lippincott Williams & Wilkins: Philadelphia, PA; 2016.

Staffing issues

The PACU nurses may express feelings of inadequacy related to critical care skills and competencies. A PACU nurse may have no ICU nursing experience or outdated critical care experience. The critical care experience may have been generalized and not specific, or new technology may be foreign. Nurse-to-patient ratios may be exceeded for safe patient care. The PACU nurse may already be assigned one patient with simultaneous care for a newly admitted ICU patient with an unstable condition. Then family members (frequently numerous) want to be present and are upset because visitation is limited or not allowed. PACU nurses may find themselves in the midst of ethical situations that involve conflict between the needs of the ICU patient’s family members, the preferences of physicians, and other health care providers. Consequently, this PACU environment may be chaotic and not conducive for healing. Visitors may perceive the PACU as a suboptimal environment for their loved ones. When PACU nursing staff members perceive that safe patient care is becoming jeopardized or at high risk, they should consult the nurse manager immediately.

As the nursing shortage in the United States has become more severe, placing ICU overflow patients in the PACU has become a standard of practice rather than being a series of isolated incidents.8 Reports from PACU nurses in different regions of the country have communicated unsafe practices. PACU nurses turned to their professional organization, the ASPAN, to voice their concerns about serious issues that affect the care they provide to recovering ICU patients in the PACU. The ASPAN Standards and Guidelines Strategic Work Team conducts an annual review of critical care nursing evidence to identify current nursing practice issues. The following trends in the care of ICU patients in the PACU are commonly identified:

  1. 1. Staffing requirements identified for Phase I PACUs may be exceeded during times when PACUs are used for ICU overflow patients.2,7
  2. 2. Phase I PACUs may not be able to receive patients normally admitted from the OR when staff is used to care for the ICU overflow patients.2,7
  3. 3. The PACU Phase I nurse who has not been properly trained nor has the required ICU nursing competencies may be required to provide care to a surgical or nonsurgical ICU patient.2,7
  4. 4. Because caring for ICU overflow patients in PACU Phase I does not occur on a regular basis, both the PACU and the hospital management may not be properly prepared to handle the admission and discharge of PACU Phase I and ICU patients.2,7

The ASPAN Board of Directors endorsed the Position Statement on Patient Flow/Throughput in Phase I PACU by encouraging all members to actively pursue education and competencies required for the care of the critically ill and other surgical patients. Likewise, organizations need to set policies which identify the medical management of the appropriate overflow population with collaborative strategies to promote safe, competent quality care regardless of where the ICU patient is recovering2,19 (Box 55.2).

Box 55.2

POSITION STATEMENT 3. A Position Statement on Patient Flow/Throughput


The American Society of PeriAnesthesia Nurses (ASPAN) has a responsibility to define principles of safe, quality nursing practice in the perianesthesia setting. ASPAN, therefore, has the responsibility to assist in defining the management of patient throughput/patient flow through the perianesthesia environment. Based on a review of the current published literature and available national standards, this position statement summarizes the criteria to be met during times of disrupted patient throughput/patient flow in Phase I postanesthesia care units (PACUs), and provides expectations for professional perianesthesia nursing practice.


Hospitals across the United States continue to experience challenges in effectively coordinating patient admissions with discharges, commonly referred to as “throughput.” The increase in patient capacity brought about by challenges associated with the management of throughput disrupts patient flow through the perianesthesia setting, with many Phase I PACUs becoming overcrowded with overflow patients, also referred to as “boarders, extended stay, or critical care overflow patients.”1 The disruption of patient flow through the perianesthesia setting often interferes with the ability of the Phase I PACU to provide care to postanesthesia patients while maintaining the flow of the OR.1,2 In addition, the delivery of ongoing safe and effective care to boarders, extended stay, or critical care overflow patients requires essential clinical knowledge and skills.

Staffing criteria for the critical care patient should be consistent with facility-specific critical care guidelines and based on individual patient acuity and needs.3,4 Staffing criteria for the medical/surgical patient should be consistent with facility-specific guidelines and based on individual patient acuity and needs.2,[a]

Disrupted throughput/patient flow through the perioperative environment, influenced by many factors, such as prolonged length of stay in the PACU due to perioperative complications and/or lack of available inpatient beds, has the potential to alter the workflow of the perianesthesia nurse and compromise the quality of patient care that is delivered. A review of the literature identified the following trends:

  1. 1. Staffing requirements and workload identified for Phase I PACUs may be exceeded during times when PACUs are being utilized for boarders, extended-stay, or critical care overflow patients.1,2,5
  2. 2. PACUs may be unable to receive patients normally admitted from the OR when staff is being utilized to care for overflow patients.1,5
  3. 3. Because caring for boarders, extended-stay, or critical care overflow patients may not occur on a regular basis, both PACU and hospital leadership may not be properly prepared to deal with the care and management of these patients in addition to postanesthesia patients.1,4
  4. 4. The Phase I PACU RN may be required to provide care to a surgical or nonsurgical critical care patient without proper training to care for or without the required care competencies validated.3,5
  5. 5. Medical management responsibility has not been consistently identified.
  6. 6. Staffing criteria for the ICU patient should be consistent with facility-specific ICU guidelines and based on individual patient acuity and needs.4


It is the position of ASPAN that the primary responsibility for Phase I PACU is to provide the optimal standard of care to postanesthesia patients and to effectively maintain the flow of the OR schedule.2 The primary goal for the postanesthesia patient is to ensure the best environment for the patient, aligning both nurse and physician characteristics, knowledge, and skills. The following criteria must be met to ensure the safe and effective care of all perianesthesia patients, including boarders, extended stay, and/or overflow critical care patients during times of disrupted throughput/patient flow:

  1. 1. Patients whose surgery has been completed, yet are unable to be admitted to the PACU, should receive the same standard of care for Phase I PACU until there is an available bed in the PACU.
  2. 2. Appropriate staffing requirements must be met to maintain safe, competent nursing care of the postanesthesia patient as well as the boarder, extended stay, and/or critical care overflow patient.2,4,6
  3. 3. Staffing criteria for these patients should be consistent with facility-specific guidelines for the specified level of care and based on individual patient acuity and needs.4
  4. 4. All boarders, extended care, and/or overflow patients in PACU and ASU units should receive the same standard of care provided by inpatient units.
  5. 5. Phase I PACUs are, by their nature, critical care units and, as such, members of the health care team should meet the competencies required for the care of the critically ill patient. These competencies should include, but are not limited to, ventilator management, hemodynamic monitoring, and medication administration, as appropriate to their patient population.2,3,4
  6. 6. All perianesthesia RNs must maintain the appropriate competencies for the boarders, extended stay, and/or overflow patients being cared for in their perianesthesia unit.
  7. 7. Critical care nurses providing Phase I recovery should also meet the competencies necessary to provide postanesthesia care to patients.4
  8. 8. Management should develop and implement a comprehensive resource utilization plan with ongoing assessment that supports the staffing needs for the patient in the PACU when patient throughput/patient flow is disrupted.2
  9. 9. Management should have an interdisciplinary plan to address appropriate utilization of beds. Admission and discharge criteria should be utilized to evaluate and determine the priority for admissions.3,6
  10. 10. Medical management of the patient must be established, including who is in charge of the patient’s care while in PACU.

Expected Actions

ASPAN recognizes the complexity of caring for patients in a dynamic health care environment where reduced availability of resources and expanding roles for the perianesthesia RN has an impact on patient care. Thus, we encourage all members to actively pursue the education and development of competencies required for the care of the critically ill and other surgical patients in the perianesthesia environment. We encourage organizations to set policies which identify the medical management of the extended care of surgical patients in this population. We also encourage members to actively identify strategies for collaboration and problem solving to address complex staffing issues.

This information and position statement is to be shared with all individuals, organizations, and facilities involved in the care of overflow patients in the perianesthesia environment.

Approval of Statement

This statement is a combination of A Joint Position Statement on ICU Overflow Patients and A Position Statement for Medical-Surgical Overflow Patients in the Postanesthesia Care Unit and Ambulatory Surgery Unit. The modified statement was presented for the 2019-2020 Standards and, as such, was endorsed by a vote of the ASPAN Board of Directors on April 28, 2018, in Anaheim, California, and approved by a vote of the ASPAN Representative Assembly on April 29, 2018, in Anaheim, California.

This Position Statement was reviewed and updated at the October 2019 meeting of the Standards and Guidelines Strategic Work Team in Dallas, Texas.


  • 1 Lalani S.B., Ali F., Kanji Z. Prolonged-stay patients in the PACU: A review of the literature. J Perianesth Nurs. 2013. ;28(3):151–155. doi:10.1016/j.jopan.2012.06.009. 23711311.
  • 2 American Society of PeriAnesthesia Nurses. Practice recommendation 1: patient classification/recommended staffing guidelines. In: 2019-2020 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. ASPAN; 2018.
  • 3 Clifford T. The ICU patient. J Perianesth Nurs. 2010. ;25(2):114–115. doi:10.1016/j.jopan.2010.01.012. 20359648.
  • 4 Hardin S.R., Kaplow R., eds. Synergy for Clinical Excellence: The AACN Synergy Model for Patient Care. 2nd ed. Jones & Bartlett Learning; 2017.
  • 5 Mamaril M.E., Sullivan E., Clifford T.L., Newhouse R., Windle P.E. Safe staffing for the postanesthesia care unit: weighing the evidence and identifying the gaps. J Perianesth Nurs. 2007. ;22(6):393–399. doi:10.1016/j.jopan.2007.08.007. 18039511.
  • 6 The Joint Commission. The “patient flow standard” and the 4-hour recommendation. Jt Comm Perspect. 2013;33(6):1,3–4.
  • 7 Hegedus M.B. Taking the fear out of postanesthesia care in the intensive care unit. Dimens Crit Care Nurs. 2003. ;22(6):237–244. doi:10.1097/00003465-200311000-00001. 14639111.

Additional Reading

  • 1 American Association of Critical Care Nurses. AACN Standards for establishing and sustaining healthy work environments: a journey to excellence. 2nd ed. 2019.; .
  • 2 Barone C.P., Pablo C.S., Barone G.W. Postanesthetic care in the critical care unit. Crit Care Nurse. 2004. ;24(1):38–45. doi:10.4037/ccn2004.24.1.38. 15007891.
  • 3 Kaplow R. Safety of patients transferred from the operating room to the intensive care unit. Crit Care Nurse. 2013. ;33(1):68–70. doi:10.4037/ccn2013866. 23377159.
  • 4 Mamaril M.E. Standards of perianesthesia nursing practice: advocating for patient safety. J Perianesth Nurs. 2003. ;18(3):168–172. doi:10.1016/s1089-9472(03)00084-4. 12808513.
  • 5 Odom-Forren J., ed. Drain’s PeriAnesthesia Nursing: A Critical Care Approach. 7th ed. Elsevier; 2018.
  • 6 Odom-Forren J. The PACU as a critical care unit. J Perianesth Nurs. 2003. ;18(6):431–433. doi:10.1016/j.jopan.2003.10.001. 14730529.
  • 7 Weissman C. The enhanced postoperative care system. J Clin Anesth. 2005;17:314–322. doi:10.1016/j.jclinane.2004.10.003.

    Reprinted with permission from the American Society of PeriAnesthesia Nurses (ASPAN): A Position Statement 3: A Position Statement on Patient Flow/Throughput. In: 2021-2022 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements. ASPAN: 2020.

    [a]Challenges associated with patient throughput should not impact the need to provide appropriate care to meet the particular needs of the patients without compromising acceptable standards of care for the population being served.

    Critical Care Educational Competencies

    The PACU nurse must have in-depth knowledge of anesthesia agents, normal physiology, pathophysiology, and current surgical management to plan appropriate nursing interventions and to care for the postanesthesia patient. Depending on the PACU nurse’s critical care experience, competencies, skills, and available medical and nursing resources, the care and management may prove to be frustrating or threatening.3 However, one should remember that the PACU nurse is recognized for possessing critical care competencies and skills when caring for the vulnerable patient recovering from anesthesia and surgery. Likewise, the challenge of caring for the complex ICU patient can be a rewarding opportunity to use one’s critical thinking skills in making a difference in the outcome of the critically ill patient.3

    Orientation and Basic Critical Care Competencies

    The first steps in planning an orientation to the PACU is the interview process and subsequent hiring of the nurse who is motivated to learn many new skills. In addition, the nurse who seeks to be professionally challenged on a daily basis inspires and motivates the critical care preceptor. The PACU should never be viewed as a place to wind down or retire, because nurses with that goal in mind are often immediately disappointed and dissatisfied with their PACU position. Many PACUs prefer to hire nurses with critical care experience. Medical-surgical nurses are also hired provided that an adequate support system of nursing education exists during orientation and the length of orientation is such that the nurse without prior critical care experience has ample time to master the myriad new skills essential to the new role.

    Orientation to the PACU must focus on anesthesia and complications related to anesthetic agents, comorbidities, and surgery, because this subject area encompasses almost the entire patient population in the PACU. But what about the critical care patient? All patients who arrive in the PACU, regardless of invasive lines and mechanical ventilation, must be viewed as having the potential to be a critically ill patient.3 Even a patient who has had a hernia repair or an appendectomy can suddenly deteriorate, become hemodynamically unstable, and gravely ill. In addition to this fact is the matter of the critically ill patient who arrives in the PACU before the final destination of the ICU. The nursing curriculum development and critical orientation should focus on the following essential educational components:

    •  Cardiac monitoring, hemodynamics, rhythm interpretation, electrocardiogram interpretation
    •  Airway management

      •  Bag-valve-mask management
      •  Nasal and oral airways
      •  Endotracheal tubes
      •  Laryngeal mask airways
      •  Intubation
      •  Extubation
      •  Weaning, spontaneous breathing, and sedation titration

    •  Arterial blood gas interpretation
    •  Mechanical ventilation

      •  Modes
      •  Appropriate tidal volumes
      •  Concept of positive end-expiratory pressure and pressure support
      •  Adequate rate and methods of delivery
      •  Assessment of adequate endotracheal tube placement
      •  Adequate securing of endotracheal tubes per nursing policy
      •  Concept of troubleshooting ventilator alarms
      •  Demonstration of ventilator weaning criteria

    •  Invasive monitoring equipment—the care and assessment of the patient with
    •  Arterial lines

      •  Radial
      •  Brachial
      •  Femoral

    •  Central lines

      •  Basic multiple lumen
      •  Advanced venous access devices

    •  Pulmonary artery (PA) catheters

      •  Assessment of correct placement
      •  Ability to perform cardiac outputs
      •  Interpretation of cardiac output, cardiac index, stroke volume, systemic vascular resistance, left ventricular stroke work index

    •  Titration of medications based on previous values
    •  Pharmacology

      •  Anesthetic agents
      •  Vasopressors
      •  Sedatives and analgesic agents

    •  Neurology and intracranial access (intracranial pressure [ICP])

      •  Neurologic assessments
      •  ICP monitoring, cerebral perfusion pressures (CPPs)
      •  Monitoring and drainage

    •  Renal: Continuous renal replacement therapies

      •  Slow continuous ultrafiltration
      •  Continuous veno-venous hemofiltration
      •  Continuous veno-venous hemodialysis
      •  Continuous veno-venous hemodiafiltration

    Orientation should include the essentials of how to care for the patient who has all or some of the invasive monitoring equipment mentioned previously and how to assemble such equipment in preparation for insertion in the PACU. The PACU should have the necessary equipment readily available in the event that a patient’s condition worsens and invasive procedures are to be performed in the PACU.

    The main challenge in orienting the newly hired nurse to the critical care elements of the PACU is access to these patients. A day in the OR with an anesthesia provider who inserts a PA catheter and manages a critically ill patient, such as with a cardiac bypass case, can be helpful. An immersion in the ICU is another option, with the PACU registered nurse (RN) spending 1 week or more in the ICU shadowing an ICU nurse. A cardiothoracic ICU is ideal because this type of ICU admits patients frequently, similar to the PACU, and the orientee can learn the tasks of detangling lines, managing the newly ventilated patient, weaning the patient, initiating and titrating vasopressor medications, and other needed skills. The leadership team of the PACU should closely collaborate with the leadership team of the ICU to ensure that the PACU RN has an orientation similar or identical to the orientation of the new nurse in the ICU. If the ICU educator or clinical nurse specialist is providing education for the ICU staff members, the PACU RNs should be encouraged to attend as well. Some ICUs use the online orientation program sponsored by the American Association of Critical-Care Nurses (AACN). This program is called Essentials of Critical Care Orientation, which is a computer-based standardized orientation of critical care nursing.20 If the ICUs in the facility use this type of orientation program, the PACU nurse might be helped by using it as well. If the ICU orientation consists of critical care courses, then the PACU trainee should attend as well after the essentials of perianesthesia nursing and PACU core competencies have been mastered.

    But what about the experienced PACU nurse who is suddenly challenged with the increasing volume of critical care patients? Collaboration with the ICU leadership team is helpful, with the possible outcome of an opportunity to shadow an ICU nurse for 1 week or more to learn the basic care and management of the patient with both mechanical ventilation and invasive monitoring equipment that requires vasopressor support.

    A competency-based orientation checklist should be completed for the new nurse and the experienced PACU RN who receives any education in critical care. The PACU leadership team must develop a standardized educational process with the requisite paper trail to safeguard the PACU RN, the hospital, and the PACU leadership team in the event of an untoward outcome.

    In addition, if the facility sponsors an annual skills fair day, the PACU RN should complete or show similar competencies to the ICU RN based on the patient population that the PACU cares for, even if that critical care population is rare. The care of a patient who is high risk and low volume is the most challenging for the RN.

    The PACU RN should also be expected to complete the same annual competence assessment required of the ICU nurses. For example, if a dysrhythmia competency is developed for the ICU RN, the PACU RN should also be expected to complete it, and documentation of completion should be placed in the individual’s education folder.

    Advanced Critical Care Concepts

    Understanding key advanced critical care concepts assists the PACU nurse in refining critical decision-making skills. The ICU patient who remains in the PACU for an extended period of time poses an enormous challenge. Both the nursing and physician management of these patients can be complex and difficult. The standards of care that are developed by the ICU and the facility and that are in place in the ICU should be readily available and implemented in the PACU. These standards include

    •  Frequency of line and tubing changes
    •  Frequency of endotracheal tube rotation
    •  Frequency of the need to prone COVID-19 patients on ventilators
    •  Frequency of ICP and CPP measurements
    •  Frequency of measurements (e.g., cardiac outputs and indexes)
    •  Frequency of weighing the patient
    •  Frequency of chest radiographs, electrocardiograms, and laboratory studies
    •  Use of a continuous cardiac output type of PA catheter
    •  Use of warming devices for intravenous fluids or blood products
    •  Use of rapid infusers
    •  Frequency of, and ability to perform and manage, the calculation of oxygen consumption, oxygen demand, oxygen extraction ratios, and other elements of oxyhemodynamic calculations (“oxy-calcs”)
    •  Various modes of mechanical ventilation, including pressure-controlled ventilation
    •  Care of the patient with continuous infusions of muscle relaxants and twitch monitors
    •  Competency with protocols in the prevention of ventilator-acquired pneumonia
    •  Competency/knowledge of protocols in the prevention of deep vein thrombosis

    Creating a Specialized Critical Care Resource for the PACU

    Many PACUs across the country care for ICU patients sporadically. This situation occurs when the hospital census is high or when a surgical emergency presents. Specialized critical care educational resources strategically provide the PACU nurse with expert advisors when the critical time arises. This resourceful method can be accomplished in several ways. First, the PACU can recruit expertise from the unit. Second, the nurse manager may elect to request key leadership staff to orient and become competent and proficient in managing the care of specific patient populations. Another foundational concept to achieving critical resources is cross-training the PACU staff to the ICU and critical care nurses to the PACU. When the PACU admits a highly complex high-acuity ICU case and the primary nurse does not possess the knowledge or skill to provide care, an opportunity may exist to exchange nurses or even practice the innovative postanesthesia critical care “team nursing” concept to more appropriately match the critically ill patient’s severity so that the PACU nurse gains important knowledge, experience, and competencies. This new model became exemplary when hospitals in the United States experienced surge capacities in their ICUs during the COVID-19 pandemic.

    Clinical strategies for the complex icu patient

    The PACU nurses are required to use critical decision-making skills in daily practice. Advanced life support competencies are mandated for PACU nurses who care for all vulnerable patients emerging from surgery and anesthesia. The foundation of PACU and critical care nursing is an understanding of anesthesia agents and human physiology that guides the postanesthesia nursing assessments and interventions. Foremost, the PACU nurses must ensure that adequate oxygenation, ventilation, transport, and perfusion in the patient occur regardless of unit—the ICU or the PACU. Impairment in oxygen delivery and utilization at the tissue level leads to global tissue hypoxia. Fundamental to recognition and treatment of global tissue hypoxia is knowledge of the principles of oxygenation, ventilation, transport, and perfusion and their etiologies and how they relate to postanesthesia care. The major differences lie in the complex pathophysiologic disease processes that occur in these critically ill patients. The following section discusses the pathophysiology and clinical strategies in management of the care for four highly specialized, high-acuity, low-volume populations: the neurosurgical, burn, septic, and COVID-19 ICU patients.

    Complex specialized critical care in the PACU

    Postoperative Care of the Neurosurgical ICU Patient

    The reasons for neurosurgical interventions are numerous. Some of the most common neurosurgical procedures that require intensive care monitoring after surgery include spine surgeries, aneurysm clipping or coiling, tumor removal or debulking, and cranial surgeries to manage increased ICP. The care of the patient who has had a neurosurgical procedure requires an understanding of the goals for the surgical procedure and continuous focused assessment for the presence of subtle neurologic changes in the patient after surgery. Specifically, the nurse should know the following: (1) the type of surgical procedure the patient underwent, (2) the length of the operative procedure and any known complications during the surgery, (3) the specific region of the brain in which the operation was performed, and (4) the preoperative neurologic examination results to allow comparison with postoperative neurologic assessment results. Often the neurosurgical procedure is referred to as the primary injury due to tissue disruption and inflammation. The following factors can be mitigated to reduce secondary injury that may further compromise a patient’s recovery: hypoxemia (oxygenation) hypercarbia (ventilation), hypotension, and hyperthermia.21,22 Primary goals in the immediate phase of perioperative care of the patient focus on optimizing cerebral blood flow (CBF) through blood pressure management, optimizing oxygenation and ventilation, maintaining normothermia, and effectively identifying signs of increased ICP to prevent cerebral edema.

    Brief Review of Intracranial Pressure

    One of the greatest risks after surgery is increased ICP. Nurses who provide care to neurosurgical patients must be familiar with the pathophysiology of increased ICP and interventions to minimize the negative effects of prolonged increased ICP that may cause brain injury. Cerebral insult of a variety of mechanisms causes chaos inside the cranial vault.22,23 Edema and increased ICP are frequently a consequence of injury. Common causes of increased ICP in the postoperative period include intracranial bleeding and cerebral edema. Additionally, seizure activity can occur in patients who have undergone a surgical procedure in areas of the brain above the tentorium.

    ICP is the pressure normally exerted by cerebrospinal fluid (CSF) that circulates around the brain and spinal cord and within the cerebral ventricles.24 Normal ICP is 5 to 15 mm Hg; however, 15 mm Hg is often considered the high end of the normal range and pressures greater than 20 mm Hg are treated rapidly.24,25 The cranial vault contains three primary elements: brain tissue (80%), CSF (10%), and blood (10%). The Monro-Kellie hypothesis treats the cranial vault as a closed compartment; therefore, if one of these three components increases, reciprocal changes in the other two components must occur to maintain normal ICP.24,25 For example, if brain tissue swells, CSF production is decreased or displaced into the basal subarachnoid cisterns, and the cerebral vasculature constricts to compensate for brain tissue edema.24Compliance refers to the ability of these compensatory mechanisms to attempt to maintain a steady relationship between volume and pressure within the cranial vault. Displacement of CSF and vasoconstriction, however, is limited, and when the limit is reached, ICP increases.

    ICP can be measured with an intraparenchymal catheter or a ventriculostomy (also called an external ventricular drain [EVD]). Both devices are surgically placed with sterile technique and should be transduced to a monitor to allow assessment of the ICP waveform. The intraparenchymal catheter displays a continuous ICP reading in addition to the ICP waveform. The ventriculostomy can be used to monitor ICP and drain CSF. The pulse wave arises primarily from arterial pulsations and to a lesser degree from the respiratory cycle.24,25 Assessment of the ICP waveform provides valuable clinical information regarding cerebral compliance. The ICP waveform has three peaks known as P1, P2, and P3 (Fig. 55.1). P1 is the percussion wave and originates from pulsations of the arteries and choroid plexus; P2 is the tidal wave and terminates in the dichroic notch; and P3 is the dichroic wave, which immediately follows the dichroic notch.24,25 The P2 wave is a reflection of intracerebral compliance; a rise in ICP is reflected by a progressive rise in P2 and a concomitant rise in ICP numeric reading on the monitor (Fig. 55.2). Analysis of the ICP waveform along with the ICP value and neurologic assessment are used to determine interventions to reduce ICP.

    Wave shows three peaks almost of same sizes. Three regions of first peak are marked P 1 through P 3. P 1 is higher than P 2, which is higher than P 3.
    Fig. 55.1 Normal intracranial pressure waveform. (From Urden L, Stacy KM, Lough ME. Critical Care Nursing. 9th ed. Elsevier; 2022. Fig. 22.16.)

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    May 20, 2023 | Posted by in NURSING | Comments Off on Care of the Intensive Care Unit Patient in the PACU

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