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PACU Rotation ​

Your time in the PACU will be very different from your OR rotations. Your role in the PACU is to serve as an easily accessible and reliable physician resource to the PACU staff. You will gain valuable experience managing patients in the postoperative setting and may be the first person called for any PACU complications or emergencies.

Hours: Monday through Friday, 10:00 am to 8:00 pm

There currently is a PACU resident CISCO phone (extension 34398) that you should carry with you or forward to your personal phone. As we transition to using our own devices, you may have to assign yourself to the PACU care team, if the option becomes available. To facilitate easy and efficient communication with nursing staff, it is recommended that you write your name and number on the whiteboard by the charge desk and confirm your number to nurses during handoffs.

There is a designated PACU resident computer at the main PACU desk near the large status boards. The PACU nurses prefer that you sit here during the day (unless at lunch, lecture, or seeing patients) so they know where to find you if they need help with something.

The majority of your day will be focused on receiving patients in the PACU from the ORs, assisting with the ongoing management of patients as needed or requested by the team or the PACU nurse, and assessing patients for discharge from the PACU. A generic sequence of events for patient care in the PACU is as follows:

Assess patients as they arrive in the PACU from the OR. Ideally, listen to sign-out from the OR anesthesia team and ask if they anticipate any post-operative problems (nausea, hypotension, challenging pain management, etc.

Address any issues or emergencies as needed. Call the in-room anesthesia attending or the anesthesia charge attending if you think you might (or definitely) need back-up. The attendings prefer that you get in touch with them pre-emptively, even if you don’t necessarily need their help, instead of not being informed and potentially getting into a dangerous situation later on. The following are examples of situations that should always be communicated to the charge or in-room attending as soon as possible (depending on time of day and who is still in-house):

  • Refractory hypotension or hypertension (e.g., giving multiple boluses of vasoactive medications and/or before starting vasoactive infusions).
  • Refractory postoperative pain (e.g., before you order ketamine, methadone, propofol, or drips, and/or contacting APS about performing a block or neuraxial procedure).
  • Altered mental status (e.g., before calling a stroke alert, ordering naloxone, etc.)
  • Refractory hypoxia (e.g., not responsive to incentive spirometry, coughing, deep breathing, or patient is too somnolent to engage in these maneuvers; rapidly escalating oxygen requirements; apnea).
  • Emergencies. These include codes, re-intubations, suspected laryngospasm, bronchospasm, or other form of airway compromise, severe hemodynamic instability (this includes profound hypotension/shock and unstable arrhythmias e.g., high grade heart block), hemorrhage, etc. A good rule to follow during this rotation is to call for back-up if you are even slightly unsure of what to do in one of these situations.

Assist with any challenges in patient disposition from PACU. You may be requested to assess a patient and communicate with surgical teams, consult teams, etc if a patient needs a higher level of care after the PACU or is unable to safely discharge home. However, these orders should always be placed by the primary team.

Prior to discharging the patient from the PACU, inform the in-room anesthesia attending or the anesthesia charge attending of any changes in disposition (if applicable). You can help bycompleting the Anesthesia Attending Post-Operative note in Epic, though not necessary.

Anesthesia Assistant students are now rotating through the PACU and may be scheduled to work with you. You will be contacted by an AA coordinator with the dates ahead of time. They primarily shadow the PACU resident but can assist with any clinical tasks as appropriate.

Daily Workflow ​

  • 10 am - Arrive in PACU, pick up the resident phone, and check in with the PACU charge nurse.

  • 10:15 am - Attend the PACU nurses’ morning huddle. During this time, you will get an overview of the number of patients expected to go through the PACU that day, as well as the acuity and disposition of these patients (outpatient, floor, ICU).

  • 3-5 pm - Attend resident didactics when applicable. Check in with the PACU charge nurse (extension 35363) before leaving for these lectures. It is helpful to take a walk around the PACU about 30 minutes before you go to lecture to address any needs and let the nurses know you will be in lecture for the next two hours. You should also forward your phone to the charge anesthesiology attending for the duration of these lectures. This will minimize the amount of phone calls you receive during lecture and ensure that the patients in the PACU receive timely care from a nearby provider.

  • 6:45 pm - Check in with the APS Rounding resident (extension 34426) before they leave at 7:00 pm to identify any patients that may need post-op blocks.

  • 7:15-7:45 pm - The nurses will appreciate it if you do a final lap around the PACU to check on their patients and see if they need anything before you head out. Let them know that you will be leaving for the night at 8:00 pm, and that they may call the charge anesthesiology attending for any needs or concerns after that time.

  • 7:45 pm - Check in with the anesthesia charge attending (extension 85920) before you leave for the night at 8:00 pm. During this time, you should sign out any PACU patients that have active issues or may need to be watched. Check in with the PACU charge nurse a final time (extension 83563) before you leave for the night.

PACU Pearls ​

  • The PACU’s code cart and airway bag can be found under the large status boards by the main PACU desk (between bays 43 and 67) to the left of the tube station.

  • Do not start non-invasive positive pressure ventilation (e.g., CPAP or BiPAP) on any patient with upper GI anastomoses (e.g., esophagectomy, bariatric surgery, Nissen fundoplication, etc.) unless specifically approved by the patient’s surgical attending or senior resident. More often than not, they will not want you to initiate this type of ventilation.

  • You may be called for issues that should be addressed by the patient’s surgical team. Some examples include increasing quantity or change in quality of output from surgical drains, altered mental status in craniotomy patients, neurological changes or deficits in spine surgery or vascular patients, loss of peripheral pulses in vascular patients, peritoneal signs (distention, severe pain despite escalating doses of narcotics, rebound tenderness) in abdominal surgery patients, persistent oozing or frank bleeding in any patient, etc. Communicate with the surgical team if any concerns.

  • Frequent check-ins or ‘rounds’ in the PACU will build rapport with the nursing staff and help keep you informed about issues or any unstable patients.

  • If a PACU nurse calls you about a potential corneal abrasion, order the Corneal Abrasion order set in Epic and notify the in-room attending (this is more to keep them in the loop than to tell them that you need their help).

  • Occasionally, a patient will require supplemental oxygen upon discharge due to postoperative hypoxia. Nurses are now able to place orders and coordinate this if the patient requires less than 2L nasal cannula. They may still request your expert opinion prior to placing orders to optimize the patient. After assessing the patient, recommendations can include incentive spirometry, albuterol inhalers, ambulation with portable pulse ox, etc. However, if the patient still requires >2L nasal cannula, you will need to place the orders and help coordinate with respiratory therapy.

  • If an anesthesiology attending approves the use of ketamine for postoperative pain and the patient did not receive ketamine during their case, PACU guidelines dictate that a physician (you) must push the first dose. After that dose, the PACU nurse may continue to administer ketamine if you order it. You may also administer the additional doses if the PACU nurse prefers. Make sure you communicate with them as to who will document these administrations, as ketamine is a controlled substance and will need to be accounted for.

  • If a patient is suffering from dissociation that you have attributed to ketamine, low-dose midazolam can help moderate this side effect. Make sure that your patient is not too somnolent and that you call your attending before ordering midazolam for this purpose.

  • Liver transplant patients may come straight to the PACU for extended stay if extubated, instead of direct transfer to the ICU. If so, you will be requested to assist with the ongoing management and resuscitation. These patients may require more attention, especially to drain output, hemodynamics, coagulation, and follow up labs, and you and the nursing staff may be the first ones to detect any clinical changes. Always communicate with the transplant surgery team if there are any concerns or interventions in these patients.

PACU Curriculum ​

There are five modules with associated quizzes on the Anesthesia Toolbox to be completed during the first half of your rotation.

You will be provided with a series of case descriptions or PBLDs during the second half of your rotation. You may work through these in person with Dr. Tamm-Daniels (or the APS attending if Dr. Tamm-Daniels is unavailable).