At the Massachusetts General Hospital, all patients who undergo GA are observed until ready for discharge, with no mandatory minimum recovery time. At least 30 minutes of observation after the last dose of opioids (or other respiratory depressant medication) is required to ensure the adequacy of ventilation and oxygenation. The criteria for recovery room discharge within a health care facility may differ depending on the procedural location (main OR, cath lab, endoscopy, interventional radiology, etc.), the resources available, and the comfort of the staff. This can be a potential source of confusion and errors, so the protocols at each site must be clear and understood by all members of the team.
To be discharged from the PACU, patients must meet several criteria. They should be easily arousable and oriented, or at their baseline. Vital signs should be stable and within normal limits. Pain and nausea should be under control. The requirement for urination or ability to tolerate clear liquids before discharge may be required in select patients. There should be no obvious surgical complications (eg, active bleeding) present. Effective communication with both the surgical team and the ward to which the patient is to be transferred can expedite the discharge of patients from the PACU. Outpatients should be discharged to a responsible adult with written instructions regarding postoperative diet, medications, etc., and with a phone number to call in case of emergency.
Fast-track recovery may be utilized for patients who meet certain criteria upon leaving the OR and are deemed ready to bypass the traditional PACU at the discretion of the anesthesia provider. These patients may be transferred directly to a second-stage recovery unit if they are ambulatory patients or to the floor if they are to be admitted as inpatients. Fast-track recovery criteria include the following:
The patient should be awake, alert, and oriented (or at the baseline state).
Vital signs should be stable (unlikely to require pharmacologic intervention).
Oxygen saturation should be 94% or higher on room air (3 minutes or longer) or at baseline.
If a muscular relaxant has been used, the patient should show no clinical signs of muscle weakness and/or the quantitative train-of-four monitoring should be greater than 0.9.
Nausea and pain should be minimal (unlikely to require parenteral medications).
There should be no active bleeding.
The intraoperative use of short-acting pharmacologic agents (midazolam, propofol, dexmedetomidine, remifentanil, succinylcholine, desflurane, and sevoflurane) and certain surgeries (orthopedic or simple gynecologic procedures) may make the fast-track recovery more likely.