PACU Assessment, ERAS, Wound Care & VTE Prophylaxis for GCC Nurses
Modified Aldrete Score Calculator
Score ≥ 9 indicates the patient is ready for discharge from PACU. Score each criterion below.
10
Total Score / 10
✓ Ready for PACU Discharge
Score
Interpretation
Action
≥ 9
PACU discharge criteria met
Transfer to surgical ward per protocol
7 – 8
Borderline — continue monitoring
Reassess every 15 min; address deficient criteria
< 7
Not ready for discharge
Senior review; consider HDU / ICU escalation
PACU Admission Checklist
Check each item on patient arrival. Progress is saved automatically.
Anaesthesia Emergence — Assessment & Management
Emergence Agitation
Common in children (paediatric emergence delirium) and elderly
Triggers: pain, full bladder, residual neuromuscular blockade, hypoxia, hypercapnia
Management: ensure adequate analgesia first, reassurance, dim lighting, parental presence in children
Propofol or dexmedetomidine for severe agitation per physician order
Always exclude hypoxia before sedating an agitated patient
Shivering Management
Affects up to 40% of post-GA patients
Increases O₂ consumption by up to 300%
Apply warm blankets, forced air warming blanket
Warm IV fluids (via fluid warmer)
Pethidine 25 mg IV (anti-shivering — MO order required)
Raise ambient room temperature in PACU
Monitor SpO₂ closely — shivering raises O₂ demand
Laryngospasm Alert
Stridor on emergence — differentiate laryngospasm (high-pitched inspiratory stridor, desaturation) from secretions. For laryngospasm: jaw thrust, 100% O₂, suction, call anaesthetist. Suxamethonium 0.5–1 mg/kg IV if complete obstruction.
Clinical Alert
Any rapid deterioration — escalate immediately using SBAR. Do not delay calling the surgical or anaesthetic team while initiating first-line management.
1. Sit patient upright 30–45° (improves FRC, reduces atelectasis)
2. Apply supplemental O₂ (start 2–4 L/min via nasal prongs, titrate)
3. Encourage deep breathing exercises + incentive spirometry (10 breaths/h)
4. Suction oropharynx if secretions present
5. Chest physiotherapy for established atelectasis
6. If opioid-induced: naloxone 100–400 mcg IV titrated (MO order) — monitor for resedation
7. CXR if clinical suspicion of pneumothorax or pulmonary oedema
Atelectasis
Most common respiratory complication. Microatelectasis in 90% post-GA. Signs: dull percussion, reduced breath sounds at bases. Rx: early mobilisation, incentive spirometry, CPAP if severe.
Pneumothorax
Consider after central line insertion, rib fracture, or thoracic surgery. Signs: unilateral absent breath sounds, tracheal deviation (tension), hypoxia, hypotension. Urgent CXR → chest drain.
ERAS is an evidence-based, multimodal perioperative care pathway that reduces complications, shortens hospital stay, and improves patient outcomes. Nurses are central to every phase.
Pre-operative Phase
Fasting: Clear fluids until 2h before, solids until 6h before (avoid prolonged starvation — causes insulin resistance, anxiety, dehydration) Carbohydrate loading: 400 mL CHO drink night before + 200 mL 2h pre-op (reduces post-op catabolism, improves insulin sensitivity) Pre-medication: Oral paracetamol, celecoxib, gabapentin (multimodal pre-emptive analgesia), antiemetic prophylaxis Patient education: Explain ERAS pathway, expected milestones, discharge goals Prehabilitation: Exercise, nutritional optimisation, smoking cessation ≥4 weeks pre-op
Intra-operative Phase
Anaesthesia: Short-acting agents (propofol TIVA, remifentanil, desflurane), BIS monitoring, avoid excessive opioids Fluid management: Goal-directed fluid therapy (GDT) — use cardiac output monitoring; avoid fluid overload (causes ileus, oedema) and hypovolaemia Normothermia: Forced air warming, warm IV fluids, theatre temperature ≥21°C Surgical technique: Minimally invasive (laparoscopic/robotic) preferred; short incisions reduce post-op pain and pulmonary splinting Multimodal analgesia: Wound infiltration, TAP/rectus sheath blocks, spinal opioids — reduce systemic opioid requirement
Post-operative Phase
Analgesia: Regular paracetamol + NSAID (if no contraindication) ± regional block; opioids as rescue only Oral intake: Encourage sips/clear fluids within 2–4h; progress to normal diet day 1 if tolerating; avoid routine NG tubes Catheter removal: Urinary catheter out by day 1–2 (prevents UTI, facilitates mobilisation) IV fluid cessation: Transition to oral fluids ASAP; IV fluids cause fluid overload and delay mobilisation Drain removal: Remove drains early if output <50 mL/24h; prolonged drains not evidence-based in most surgeries Mobilisation: See mobilisation protocol below
Early Mobilisation Protocol
PACU
Head of Bed Up
30–45°, deep breathing, leg exercises, foot pumps
Day 0
Sit Out of Bed
Dangle legs, chair × 2 sessions if haemodynamically stable
Day 1
Stand & Walk
Walk to corridor with nurse, remove catheter, discontinue IV
Day 2+
Progressive
Independent ambulation, stairs, prepare for discharge
Before Mobilising — Safety Check
Adequate analgesia given (NRS ≤3) · Postural hypotension excluded (sit→stand BP) · IPC/TED stockings worn · Drains/catheters secured · Nurse/physio present for first mobilisation
Specialty ERAS Pathways
Surgery
Key ERAS Elements
Typical LOS
Colorectal
Oral bowel prep avoided (or PEG-ELS only), early feeding day 0, epidural/TAP block, laparoscopic approach, avoid NG tube
2–3 days (vs 7+ traditional)
Hepatic / HPB
Thoracic epidural, goal-directed fluids, low CVP intra-op, early drain removal if bile-negative, physiotherapy
Laparoscopic preferred, TAP block, anti-sickness protocol (PONV high risk), early catheter removal, same-day discharge for minor procedures
0–2 days
Cardiac
Fast-track extubation (<6h), early physiotherapy, early catheter out, sternal precautions, cardiac rehab referral
4–7 days
ERAS Nurse Champion Role
Education
Pre-admission clinic: explain pathway, fasting rules, CHO loading, expected day of discharge, home care needs. Reduce anxiety through clear expectation-setting.
Compliance Tracking
ERAS nurse audits element compliance daily (fasting times, catheter removal, early diet, analgesia adherence). Feeds back to MDT. Identifies delays and escalates.
Mobilisation Facilitation
Coordinates with physio and ward staff. Ensures analgesia before mobility. Documents achievements. Coaches patient and family on home exercise programme.
Mechanism: negative-pressure vacuum suction
Management: measure and document output every 4–8h; compress/re-evacuate bulb to maintain suction; keep below wound level; label tubing; assess output colour and consistency
Removal: when output <30–50 mL per 8h shift (per surgical team guidance)
Open Drain (Penrose / Corrugated)
Mechanism: passive dependent drainage along outer wall
Management: large absorbent dressing; change when saturated; ensure drain does not retract into wound (secure with safety pin or disc); measure drainage on dressing
Use: biliary, perirectal, subcutaneous abscess cavities
T-Tube (Kehr's Tube) — Biliary Drainage
Post-cholecystectomy / CBD exploration
Expected bile output: 200–500 mL/day (reduces over time)
Document colour: golden yellow = normal; dark green = concentrated; blood-stained = haemobilia
Clamping trial: gradually clamp 2–6h/day before removal (day 7–10); monitor for abdominal pain and jaundice
T-tube cholangiogram performed before removal to confirm CBD clearance
Dose: 40 mg SC once daily (standard prophylaxis)
Timing: start 6–12h post-op (12h post-op if high bleed risk)
Duration: until fully mobile (min 7–10 days); extended 28–35 days for THR, colorectal cancer
Monitoring: routine anti-Xa monitoring not required for standard dose
Adjust: renally dosed — CrCl <30 mL/min → switch to UFH or reduce dose (specialist input)
LMWH Contraindications / Switch to UFH
Active bleeding or high surgical bleed risk (24–48h post-op)
CrCl <30 mL/min (UFH: 5000 units SC TDS instead)
HIT (heparin-induced thrombocytopenia) — use argatroban/fondaparinux
Epidural catheter in situ (check timing — 12h before insertion, 4h after removal)
Mechanical VTE Prophylaxis
TED Stockings (Anti-Embolic Stockings)
Apply BEFORE induction of anaesthesia (legs elevate during GA)
Measure calf circumference and length (floor to popliteal fossa for below-knee; to gluteal fold for thigh-high)
Below-knee stockings most commonly used (easier to fit, equivalent to thigh-high for most patients)
Contraindications: peripheral arterial disease (ABPI <0.8), severe leg oedema, local skin conditions, DVT already present
Remove once daily to inspect skin; reapply after assessment
Replace if stretched, rolled down, or soiled
IPC / SCD (Pneumatic Compression Devices)
Sequential pneumatic compression of calf and thigh increases venous return by 60%
Apply pre-induction; continue until patient is fully ambulatory
Activate device as soon as patient positioned on table
Contraindications: acute DVT in that limb, arterial insufficiency, severe cellulitis, open wound on limb
Ensure wraps fit snugly but not so tight as to impair circulation
Document compliance — record hours worn per shift
Clinical Reminder
Early ambulation is the single most effective VTE prevention strategy. Mechanical devices are adjuncts — do not substitute for getting the patient out of bed.