Many patients emerging from the haze of an anaesthetic will experience a welcome, if-dreamlike, return to consciousness, most likely followed by a sense of overwhelming relief.

Few however are aware of the crucial role played by nurses in a Post Anaesthetic Care Unit (PACU) - also known as “recovery”; those vigilant presences charged with guiding a patient from oblivion to consciousness.

Judit Gonzalez MRCNA, a registered nurse from Sir Charles Gairdner Hospital (WA), who has spent the last three years as a post anaesthetic care specialist, muses that most of her patients will probably not remember her.

Yet despite their anonymous presence, the role played by Judit and her ilk is among the most demanding and rewarding in nursing.

Judit is so passionate about PACU nursing that she recently contributed an article in the Royal College of Nursing Australia’s publication Connections to shed light on the role. 

PACU nurses typically look after a broad range of patients, from newborns to the elderly. They operate in a fast paced environment, working with one or two patients at a time and providing specialist care before transferring them to their next destination, usually within two hours.

As part of the intensive and critical care spectrum - the only difference between PACU and ICU (intensive care unit) nursing is that the latter includes the use of mechanical ventilation - PACU nurses are charged with the task of monitoring patients in the post operative phase until they have regained consciousness, have stable vital signs and meet the PACU discharge criteria.

Typically a PACU nurse will have in depth knowledge of an aesthesia and must also be proficient in managing respiratory instability, cardiac and neurological issues and hemodynamic.

Although Judit laughs when asked about her typical day - “There’s really no such thing; every patient is different and every day brings a new set of challenges” – her shifts do follow a basic structure.

“At 7.45am the first shift starts, with the first patients usually coming out of the operating theatre at around 9 to 9.30.

Before then, we check all emergency equipment to ensure it’s in working order and re-stocked; especially the oxygen supply, suction, monitors, Lifepack (defibrillator) and intubation/emergency trolley.

When surgery finishes, we receive a call from the theatre staff letting us know that the patient is coming out. At this moment the PACU Coordinator assign the patient to one of us, as well as a bed space where the patient will be recovered.”

The patient in situ, the PACU nurse connects the mask to the oxygen supply and then monitors the patient, including oximetry (measuring the oxygen content of the blood), CO2 monitoring, blood pressure (invasive if there is an arterial line in situ, or non-invasive), temperature and ECG or CVP when needed.

The nurse then receives a full handover from the escorting theatre nurse and Anaesthetist and checks that documentation is complete.

“We assess the patient immediately following transfer from the operating room for airway potency and level of consciousness. We always remain at the bedside of the unconscious patient, monitoring and recording sedation level and vital signs every 15 minutes.”

If the patient’s temperature is less than 35.5 degrees, the PACU nurse commences re-warming procedures as soon as possible, while also ensuring that adequate steps are taken to alleviate pain and that medication, IV therapy and all the care ordered, is given as per best practice standards.

“We must also inform the Coordinator of significant changes in the patient’s status and consult with the Anaesthetist and surgeon as required. All the PACU documentation has to be clear and include any changes, actions or outcomes.

The PACU nurse determines patient readiness for discharge as per discharge criteria, before handing the patient over to the ward staff. The nurse is then available to recover another patient.”

Judit usually recovers around five or six patients in an eight hour shift, but this also depends on the patient’s acuity and complications during recovery. More unstable patients require one to one nursing care while paediatric patients usually require a second nurse.

The latter are rare in a PACU environment, although nurses occasionally participate in paediatric patients’ recovery after angiography procedures done under sedation or general anaesthesia.  

Just some of the many other skills in a PACU nurse’s remit include electrocardiogram monitoring (management of arrhythmia); central venous pressure and intracranial monitoring; fluid balance management; blood or blood product transfusion; and arterial blood sampling to monitor a patient’s ongoing respiratory, cardiovascular and post-operative bleeding issues.

In a setting where missing a change in a patient´s condition could be life threatening, PACU nurses must also be able to think critically and efficiently and be able to identify the risk of complications for post-surgery patients.

It goes without saying that the ability to stay calm under pressure and communicate effectively with the theatre and post-operative team are key prerequisites for the job.

If there’s a downside it’s the pressure of dealing with rapidly changing situations, such as a patient whose condition is unstable or who encounters potentially life threatening issues.

Thankfully, these are largely alleviated by a structured debriefing system.

“We have meetings every week, where we are able to talk with a dedicated recovery manager about any issues or challenges we may have encountered,” Judit confirms.

For her, any qualms are far outweighed by the upside of the job. “I love it,” she says simply. Having left her native Spain to work in the UK, she initially “fell into” PACU nursing when a hospital in Essex required recovery nurses. She hasn’t looked back.

Students searching for their niche in nursing are a regular fixture at Judit’s unit. They stay for two-week stints and find themselves challenged and rewarded.

With numbers limited to one student in the unit at a time, they gain in-depth experience of the varied nature of the role. More often than not, they leave the unit well and truly “hooked.”

“One of the best aspects of working in PACU is that you really get to know your job deeply. A ward nurse will have many different patients with many different conditions to look after, and in those situations it’s quite hard to get to know your job properly.

By contrast, working as a PACU nurse provides a great deal of confidence in and satisfaction with your work.”