The PACU should be located as near to the ORs as possible, if need arises to take the patient back there (see Box 17.1). Usually, patients are observed in the PACU in open designated areas. Few spaces are designated “enclosed” areas to observe patients needing isolation. Each PACU space should be well lighted, easily accessible, and should have enough space available for equipment such as a ventilator or an x-ray machine. In addition, outlets for oxygen and suction should be available.

Standard equipment for monitoring a PACU patient should include a pulse oximeter, electrocardiograph (ECG) and an automated blood pressure cuff (see Box 17.2). Transducers for monitoring arterial, central, and pulmonary artery pressures should be available (see Box 17.3). Temperature is usually determined by the PACU nurse on the patient’s admission to the PACU. If hypothermic, the patient can be warmed using a forced air-warming device.

Once the surgery is completed, the patient is transferred to a stretcher to be taken to the PACU. Oxygen supplementation should be available and given to the patient through nasal cannula/face mask connected to an appropriately full oxygen tank. Monitors with the ability to monitor pulse oximetry, ECG, and blood pressure should be available, if needed. On reaching the PACU, oxygen supplementation is switched to a wall source and the patient is appropriately monitored (pulse oximetry, ECG, and blood pressure). Finally, a report is given to the PACU nurse with details about the anesthesia given and the surgery performed.

Fully trained nurses should be available to take care of the patients in the PACU. The PACU should be under the direct medical direction of the anesthesiologist, if possible. The anesthesiologist usually manages analgesia, pulmonary, or cardiac complications, whereas the surgeon usually manages complications directly related to the procedure. A PACU nurse is assigned to take care of not more than two patients at any given time. Depending on the complexity of the surgery and the severity of the illness of the patient, a PACU can be divided into a regular PACU area, a secondary recovery area (SRA) mainly for ambulatory surgical patients, and an extended observation unit (EOU) for patients needing >4 to 6 hours to be discharged from the PACU.

Although these designations are ideal for an ambulatory center, in the office-based setting, the areas might not be as well defined. However, the principle and premise should remain the same.

Discharge from the PACU usually depends on meeting all or most of the criteria mentioned in Box 17.4 and Table 17.1. The anesthesiology department and the hospital administration usually set these criteria. An anesthesiologist is usually assigned to sign the patient out of the PACU. Several discharge/postanesthesia recovery scores are available (e.g., Aldrete score (6,7) and Postanesthesia Discharge Scoring [PADS] System (8)) which can be used by individual hospitals to establish discharge criteria (see Table 17.2).

Once the patient meets the discharge criteria (a score of at least 10), the patient is discharged from the PACU and should be accompanied by a designated person (family or friend) who is responsible for safe transport to home. Patients who need to be transported for further evaluation should have oxygen supplementation and appropriate monitors, as needed.

The decision to “bypass” the PACU (a score of at least 12), if at all, should be made in conference by the anesthesiologist and the surgeon. This should depend on the procedure, the patient’s comorbidities, any intraoperative events, and the amount of anesthesia administered (MAC/general anesthesia [GA]) (see Table 17.3). Along with the growing number and complexity of patients and cases, we cannot emphasize enough how important it is that all office-based facilities have the mechanism immediately available to emergently transport the patient to a nearby tertiary care hospital, if needed.