Introduction 

Post operative care and routine post anaesthetic observations are a requirement for patient assessment and the recognition of clinical deterioration in post-operative patients; acknowledging that children are at a higher risk of complications post anaesthesia, surgery and procedures.   
There is disparity in the literature as to what constitutes ‘standard’ routine post anaesthesia observations, so in line with the Observation and Continuous Monitoring Guideline, this guideline designates clinical observations and post operative care for the immediate post-operative period and assists in the recognition of clinical deterioration through use of the Victorian Children’s Observation and Response (ViCTOR) graph  containing unshaded zones in which normal observations are expected and shaded zones above and below the normal limits.

Aim 

This guideline is for the management of patients requiring inpatient stay post-operatively and applies to all patients after a general anaesthetic for whom the ‘ Post-Operative Discharge Criteria Following General Anaesthesia for Minor Surgical Procedures’ does not apply.  

This guideline provides guidance for:  

• Measurement of clinical observations in the post-operative period  
• Links to the process for escalation of care in response to abnormal physiological observations   
• Management of inpatients post operatively 

Note that this is a guideline only and does not replace the need for clinical judgment on an individual basis.

Definition of terms 

• American Society of Anesthesiologist (ASA) -is a physical status classification system. It provides grading from I (one) through to V (five) to identify the health of a patient prior to a surgical procedure requiring anaesthesia. 
• Volatile Anaesthetics- A volatile anaesthetic is administered by inhalation to induce general anaesthesia. These agents include isoflurane, sevoflurane, halothane, and desflurane.  
  

Assessment 

Initial assessment – PACU 

When admitting a patient to PACU, patient identification and handover should occur utilising the Recovery arrival handover tool in EMR.   

Post-operative orders must be communicated both verbally and documented. It is the surgeon or proceduralist’s responsibility to ensure that all post-operative orders for the patient are added to their EMR. If orders are not present, the PACU nurse will escalate to the treating team and handover to the nurse assuming responsibility for the care of the patient. Post-operative orders are additional to the operation report.   

Clinical handover in PACU should highlight any issues throughout the intra-operative period, acknowledge the process for escalation of care, should this be required, and allow for clarification of any instructions before accepting care of the patient.

Once care is accepted in the PACU the initial assessment should include:  

• Physical Assessment   
• Airway, Breathing, Circulation & Disability Assessment (refer to Nursing Assessment Guideline) 
• Baseline Observations including, RR, Respiratory effort, SpO2, HR, BP and Temperature  
• Apnoea Monitoring if applicable- Any infant who has had an apnoea in the immediate postoperative period should be considered for overnight admission and apnoea monitoring. Refer to Apnoea Monitoring Post Operatively of Infants for more information 
• Sedation Score (UMSS) 
• Nausea Score 
• Oxygen requirements    
• IV Infusions- Perform OILS check (Orders, Infusions, Lines, Securement) 
• Pain Assessment/ Analgesia Requirement 
• Urine Output  
• Reportable Blood Loss    
• Assessment of Wound Sites / Dressings    
• Presence of drains and patency of same    
• IVC- Asses, Flush, and secure. Every effort should be made to keep IVC insitu, unless clinically indicated. Refer to Management of Midline and Peripheral Intravenous Catheters nursing guideline for more information 
• Blood glucose* 

*For patients with diabetes mellitus, hourly intra and post-operative levels should be checked (including a level immediately prior to transfer to and from theatre) until tolerating oral intake. If BGL was not checked intra operatively, levels must be done immediately upon arriving in PACU. 

Blood glucose should also be checked after certain procedures, such as liver biopsies on transplanted livers, or if indicated by the anaesthetist. 

Blood glucose levels should be checked on any lethargic or unwell infant/child, a child that is difficult to rouse, or a child that may have experienced prolonged fasting 

Observations continue at least 15 minutely, or more frequently as clinically indicated  

• HR, RR, SpO2, Temperature and BP 
• Sedation Score (UMSS) 
• Pain Score  
• Nausea Score 
• Wound Site/ Dressing

PACU ‘Discharge Criteria’ 

Patients are ready to transfer to the ward once they meet the PACU ‘Discharge Criteria’ (see below) and ‘Ready for Discharge’ has been timestamped on EMR.   

Refer to Discharge from the Post Anaesthetic Care Unit Guideline for information on PACU discharge criteria.

If there is a delay in transfer of patient related to inability of inpatient unit to accept care, then observations in the PACU will continue to be 15 minutely as per Australian College of Perioperative Nurses (ACORN) standards. If delay results in the patient remaining in PACU for a significant extended period (e.g., several hours), observation frequency may be adjusted to 30 minutely, based on clinical judgment and patient stability 

If there is a delay in transfer, PACU nurses will hand over the time the patient met the PACU ‘Discharge Criteria’.

Management of Day of Surgery patients  

 Please refer to ‘ Post-Operative Discharge Criteria Following General Anaesthesia for Minor Surgical Procedures’ for day of surgery patients, this includes day of surgery patients who are admitted to an inpatient ward i.e. afterhours. 

Management of Patients requiring an Inpatient Stay

Transfer care from PACU to the ward following the patient identification policy and as per the Nursing Clinical Handover Nursing Guideline. 

Ensure: 

• Document handover has been given/received between PACU Nurse and Ward Nurse accepting care.  
• Clinical observations must be recorded before transfer from one area to another, for example from ED to ward, PICU to ward or PACU to ward  
• If a child's observations are transgressing MET criteria (i.e., in the shaded zones), this must be addressed prior to transfer. Please see the Medical Emergency Response Procedure.  
• Documentation of altered MET Criteria if required please see the Emergency Response Procedure
  

Observations

Routine Post Anaesthetic Observations (RPAO)

The time frame for routine post anaesthetic observations should commence once the PACU nurse has deemed the patient ‘Ready for Discharge’. This documentation can be located in the EMR under the ‘Chart Review’ Activity tab – ‘Anaesthetics and Perfusion’ – Click to open the procedure report and scroll down to ‘Recovery’ ‘Case Tracking Events’. The ward nurse should confirm the time when the patient was deemed ‘Ready for Discharge’ during handover.  

Note: If there is a delay in transferring a patient to the ward due to bed availability, the time the patient met the PACU ‘Discharge Criteria’ and ‘Ready for Discharge’ should be noted, so as the routine post anaesthetic observation period need not be reset. 

Observation schedule on transfer to ward

Note: Initial set of observations are to be done immediately on transfer from PACU to ward 

RPAO can be placed as an order in EMR. 

Please note: If the patient has been administered Flumazenil or Naloxone in either theatre or recovery, this increases the risk of an adverse complication/event such as respiratory depression/compromise and increased sedation/or altered conscious state. Receiving nurses should remain vigilant for changes in conscious state or level of sedation. Once a patient is discharged to the ward post flumazenil/ Naloxone administration, 15 minutely observations continue for 1 hour and normal observations thereafter. See Naloxone Flumazenil reversal flowchart for more information   

Observations Should Include  

• HR, RR, SpO2, BP and Temperature 
• Neurological Assessment (AVPU, Michigan sedation score or formal GCS) as indicated. Refer to Neurological Nursing Guideline  
• Assessment of IVC. Refer to Management of Midline and Peripheral Intravenous Catheter Nursing Guideline for more information Pain Score. See Acute Pain Management CPG 
• Assess surgical bleeding from wounds/drains/dressings. Escalate any concerns to treating team 
• Presence of drains and patency of same 
• Post-operative nausea and vomiting (PONV). Refer to PONV guideline 
• Maintenance of Fluid Balance 
• Neurovascular observations as indicated 
  

Special Considerations 

For patients with Diabetes Mellitus: Check BGL 2-4 hourly. Transition back to subcutaneous insulin in the post-op period should be discussed on an individual basis with the endocrinology team; this will vary depending on the patient's usual insulin regimen and ability to tolerate an oral diet. For more information refer to Diabetes Mellitus and Surgery CPG 

Pulse oximetry and/or cardio-respiratory monitoring:  All Patients with altered consciousness, respiratory and/or cardiovascular status should receive continuous pulse oximetry and/or cardio-respiratory monitoring throughout the routine post anaesthetic period outlined above and as indicated by patient condition.  
Refer to the Observation and Continuous Monitoring guideline for more information.  

Modified Post-Operative Orders +/- MET Modification: whilst all postoperative orders need to include both post anaesthetic and post-surgical orders, some patient groups may need modified post-operative orders +/- modification of MET criteria, these may include:  

• Patient factors: examples include increased risk of hypothermia including children with Cerebral Palsy or family history of Malignant Hyperthermia  

• Surgical factors: examples include major surgery where there has been significant blood loss  
  

For further information regarding modification on the MET criteria please see the Medical Emergency Response Procedure.  

Ongoing Observation  

At the completion of the RPAO’s, the type and frequency of clinical observations must reflect the clinical status, therapies and interventions being delivered to the child and be consistent with requirements of other individual guidelines and procedures. See ‘Observations’ above for what to consider including in ongoing post-operative patient monitoring and assessments.  

Children with complex medical conditions and ASA status 3 and above, may require increased continued observation following GA at the request of the anaesthetist.  

As per the Observation and Continuous Monitoring guideline, observations should be performed at least once per hour if the patient:  

• Has previous observations within the shaded orange or red zone (unless modified)   
• Was transferred from PICU/NICU (as clinically indicated)   
• Is receiving PCA, Epidural, or Opioid infusion 
• Is receiving an Insulin infusion 
• Has ICP monitoring 
• Is receiving oxygen therapy 
• Requires added airway support ie. NPA insitu 
• Is on apnoea monitoring  
  

Note, other children may require hourly observations and continuous monitoring as clinically indicated. Observation frequency is an order.    

• The registered nurse responsible for the child's care will determine the type and frequency of observations based on the results of previous observations and the child's clinical condition, in consultation with others involved in the child's care.

If you are concerned about the child for whom you are caring, refer to the Medical Emergency Response Procedure. 

If immediate review is required in a deteriorating child, call a MET (dial 22 22 and state building, level, ward and room number) 

Pain Management  

Typical Duration of Analgesic Modalities (Intra-Op) 

Pain assessment should be ongoing throughout a patients’ perioperative journey. Understanding typical duration of analgesic modalities ensures nurses can make informed clinical decisions, provide appropriate patient education, and contribute meaningfully to pain management strategies.  

• Caudal: Regional anaesthetic into caudal space, particularly good at providing analgesia below the umbilicus in paediatric populations. May give relief for up to 4-6 hours. Decreased sensation may result in instability when walking. 
• Opioids: May give relief for up to 2-4 hours. May result in increased sedation. 
• Local Anaesthesia: An agent which blocks the conduction of impulses in nerve tissues through sodium channel deactivation. May give relief for up to 2-4 hours-once wears off may require additional analgesia. Patients may experience a tingling sensation where local anaesthesia is wearing off. 
• Intrathecal Anaesthesia: Local anaesthetic administration into the spinal canal or into the subarachnoid space to reach the cerebrospinal fluid (CSF). May give relief up to 24 hours. May result in compromised sensation and movement resulting in potential increased risk to pressure injuries, headaches, nausea and vomiting, or dizziness. 

Concerns with pain management should be escalated to CPMS and In-Charge Anaesthetist (ext 52000) in the immediate post-operative period.  

Administration of analgesia, prior to patient mobilisation, should be considered. 

Refer to Pain Assessment and Measurement Nursing Guideline for more information on assessing, managing and documenting pain. 

For Patients with Infusions 

Refer to Nursing Guideline for management of the paediatric patient receiving opioids and Opioid Infusion pain management guideline  

Wound Care 

Post operative wound dressings should be left intact as per post operative instructions and reinforced if oozing. Contact treating team if concerned about wound or dressing. Wounds should be assessed on arrival to ward post-operatively, ½ hourly during RPAO period, and then minimum 4 hourly ongoing.  

Frequency of dressing changes: 

• Frequency of dressing changes is led by the treating team or indicated by product manufacturers 
• Accurate assessment of pain is essential when changing dressings to prevent unnecessary pain, fear, and anxiety associated with dressing changes. Prepare patients for dressing changes using pharmacological and non-pharmacological techniques as per the RCH Procedure Management Guideline.    

Documentation

Document wound care, including assessment, treatment and management plans clearly and comprehensively in the EMR under Flowsheet activity (utilising the LDA tab or Avatar activity). 

Clinical images are a valuable assessment tool that should be utilised to track the progress of wound management. See Clinical Images- Photography Videography Audio Recordings policy for more information regarding collection of clinical images. 

For further information on wound care, assessment, and management refer to Wound Assessment and Management Guideline  

Post Operative Nausea and Vomiting (PONV) 

Risk factors which could increase PONV incidence: 

Risk Factors: Age > 3 years, past history of or family history of PONV, history of motion sickness, post-pubertal female, preoperative anxiety 

Surgery type: Strabismus surgery, otoplasty, adenotonsillectomy, surgery requiring postoperative inpatient (vs day) stay, volatile anaesthesia 

Guidelines for PONV rescue treatment: 

Antiemetic options depend on what has been given intra- and postoperatively. Refer to PONV  departmental guideline for antiemetic considerations. In the immediate postoperative, contact the In-Charge Anaesthetist (ext 52000) for PONV concerns. 

Recovery and Management of Infectious Patients 

For information on management, precautions, isolation requirements, and discharge cleaning requirements of patients with infectious diseases refer to Infectious Disease Table  
* For further infection control advice, contact Infection Control ext 55740. For afterhours, contact Doctor of Microbiology (ICP) on switch. 

Surgery Specific Care Guidelines/Pathways 

Burns: 

• Nursing Management of Burn Injuries Guideline  

• Burns Unit Clinical Resource 

• Post Acute Care and Dressings CPG 

Cardiac: 

• Care of the Patient Post Cardiac Catheterisation Nursing Guideline  

• Chest Drain Management Nursing Guideline 

• Chylothorax Management Nursing Guideline  

• Peri-Operative Management of Patients with Pulmonary Hypertension or Cardiomyopathy  

• Pleural and Mediastinal Drain Management After Cardiothoracic Surgery Nursing Guideline  

Endocrinology: 

• Diabetes Mellitus and Surgery CPG 

ENT: 

• Nasopharyngeal Airway Insertion and Management Nursing Guideline     

• Tonsilectomy +/- Adenoidectomy Post Operative Nursing Management Guideline  

• Tracheostomy Management 

Gastroenterology: 

• Acute Management of Oesophageal Variceal Bleed Nursing Guideline  

• Faecal Stoma Care Nursing Guideline 

• Gastrostomy- Acute Replacement of Displaced Tubes CPG 

• Gastrostomy –Common Problems CPG 

• Gastrostomy Nursing Guideline  

• Post Operative Bowel Management Nursing Guideline  
  

General Surgery: 

• Surgical Drains (Non Cardiac) 

• Stiches and Glue Care KHI 

• Wound Catheter Mangement Nursing Guideline       

Orthopaedics: 

• Accelerated Discharge Pathway for Adolescent Idiopathic Scoliosis Patients after Posterior Spinal Fusion 

• Cast Care Nursing Guideline 

• Hip Spica Nursing Care Guideline 

• Neurovascular Observations Nursing Guideline  

• Pin Site Care for the Child with an External Fixator  

• Pressure Injury Prevention and Management Nursing Guideline  

• Skin Traction 
  

Neurosurgery: 

•  External Ventricular Drains and Intracranial Pressure Monitoring Nursing Guideline  

•  Intrathecal Baclofen Therapy Nursing Guideline 

• Neurological Observations  

Plastics & Maxillofacial: 

• Fingertip and Nail Injuries-ED CPG 

Urology: 

• Mitrofanoff Stoma Nursing Guideline 
  

Companion documents  

• Apnoea Monitoring Post Operatively of Infants 

• Clinical Handover - Policy & Procedure 

• Emergence Delirium Policy and Procedure 

• Medical Emergency Team Policy & Procedure 

• Met Criteria - Call 22 22 for help - Clinical Practice Guideline 

• Neonatal and Infant Intravenous Fluid Management Nursing Guideline  

• Nursing Assessment Guideline     

• Observation and Continuous Monitoring Guideline  

• Opioid Infusion Anaesthesia and Pain Management Guideline 

• PACU discharge guideline 

• Paediatric Injectables Guidelines 

• Patient Identification - Policy & Procedure  

• Wound assessment and management nursing guideline 

Please remember to read the disclaimer

The development of this nursing guideline was coordinated by Amy Carle, Nursing Guideline Fellow, Nursing Research and approved by the Nursing Clinical Effectiveness Committee. Updated November 2025.  

Evidence Table