Clinical Guidelines (Nursing)

Routine post anaesthetic observation

  • Introduction

    Routine post anaesthetic observations are an essential 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 anesthetics, surgeries and procedures. 
    There is disparity in the literature as to what constitutes ‘standard’ routine post anaesthesia orders, so in line with the Observation and Continuous Monitoring Guideline, this guideline designates clinical observations for the immediate post operative period. Recognition of clinical deterioration is guided with use of the ViCTOR graph. It contains coloured zones in which normal observations are expected (white zone) or orange and purple zones which identify the observations that are above, or  below, the normal limits. Clinical observations marked in the  orange or purple zone indicate the level of urgency to review a child. 


    This guideline 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 immediate post-operative period
    • Role of continuous cardio-respiratory monitoring and pulse oximetry monitoring 
    • Use of the inpatient observation graphs
    • Links to the process for escalation of care in response to abnormal physiological observations 

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

    Definition of terms

    • BP - Blood Pressure
    • GA - General Anaesthetic
    • HR – Heart Rate
    • MET- Medical Emergency Team
    • MR - Muscle Relaxants (depolarizing and non-depolarizing)
    • PACU- Post Anaesthetic Care Unit
    • RPAO - Routine Post Anaesthesia Orders
    • RR - Respiratory Rate
    • SpO2 - Oxygen Saturations


    Initial assessment - PACU

    On admission to the PACU (stage 1) post-operative orders must be communicated both verbally and documented in the EMR. Post-operative orders will be additional to the operation report. Clinical handover 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:

    • Positive Patient Identification
    • Physical Assessment 
      • Airway, Breathing, Circulation & Disability Assessment (link to Nursing Assessment Guideline)
      • Baseline Observations including, RR, Respiratory effort, SpO2, HR, BP and Temperature
      • Oxygen requirements
      • IV Fluids
      • Analgesia
      • Urine Output
      • Reportable Blood Loss
      • Assessment of Wound Sites / Dressings
      • Presence of drains and patency of same
      • NGT In situ

    The following observations continue 15 minutely

    • HR, RR, Respiratory effort, SpO2, Temperature and BP (as clinically indicated)
    • Sedation Score (AVPU, Michigan sedation score or formal GCS as indicated)
    • Pain Score
    • Nausea Score

    Continuous Oximetry monitoring should be initiated for all patients admitted to PACU
    Cardiorespiratory monitoring should be applied to all patients under 6 months of age and as clinically indicated for all other patients  

    • Further information to consider in the PACU Recovery period in preparedness for Clinical Handover to the Inpatient Unit
      • Investigations – biochemistry, procedures
      • Social history/issues
      • Education needs (patient and parent/care-giver)
      • Mobility Restrictions
      • Nutrition (NBM / Oral Intake)

    Patients are ready to transfer to the ward once they meet the PACU ‘Discharge Criteria’ (see below) and ‘Recovery Care is completed’ both of which are timestamped on EMR. 

    PACU ‘Discharge Criteria’

    • Clinical Observations within age appropriate limits
    • Observations which fall within shaded areas of clinical observation chart, MET modifications must be completed (if appropriate) as per the Medical Emergency response procedure. Anaesthetist must notify PICU outreach, bed card consultant of any MET modification and plan.
    • Core temperature 36 degrees or 36.6 degrees for neonates
    • Sedation score 2 or less (UMSS)
    • No active vomiting 
    • Pain Managed

    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 ACORN standards.

    Management once transferred to an Inpatient Unit

    The time frame for routine post anaesthetic observations should commence once the PACU nurse deems ‘Recovery Care Complete’ for the patient. This documentation is located in the EMR under ‘Chart Review’ Activity – ‘Theatre and Anaesthetics’ tab – ‘Operation’ – ‘Recovery Summary’. 
    This is likely to be the time that PACU phones the ward to request they accept care of the patient. The ward nurse should confirm the time when the patient was deemed ‘Recovery Care Complete’ during handover. 
    Note: if there is a delay in transferring the patient to the ward due to bed availability, the time the patient met the PACU ‘Discharge Criteria’ and ‘Recovery Care Complete’ should be noted, so as the routine post anaesthetic observations period need not be reset.

    When transferring care from PACU to the ward the initial assessment should include:

    • Positive Patient Identification 
    • Physical Assessment of patient including Airway, Breathing, Respiratory effort,Circulation & Disability (Link to Nursing Assessment Guideline)
    • Clinical Handover 
    • Actual Complications / Potential Complications Identified 
    • Documentation that Handover has been given/received between PACU Nurse and Ward Nurse accepting care (link to nursing documentation guideline)
    • Documentation of altered Emergency Response Criteria if required (link to Medical Emergency Response Procedure

    Frequency of routine post anaesthetic observations:

    • Immediately on transfer from PACU to ward
    • Continue ½ hourly for 4 hours if the patient had an Endotracheal Tube placed
    • Continue ½ hourly for 2 hours if the patient had a Laryngeal Mask placed 
    • Continue ½ hourly for 1 hour if the patient had a Face Mask placed 

    Routine post anaesthetic observations should include:

    •  RR, Respiratory effort, SpO2, HR, BP and Temperature
    • Neurological Assessment (AVPU, Michigan sedation score or formal GCS as indicated)
    • Pain Score
    • Assessment of Wound Sites / Dressings
    • Presence and patency of drains
    • Other complications/assessment findings as patient condition dictates (link to Nursing Assessment guideline)

    Routine post anaesthetic observations should include:

    Consider the need for continuous pulse oximetry and/or cardio-respiratory monitoring as indicated by patient’s condition. 
    All Patients with altered conscious, respiratory, 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 & continuous monitoring clinical guideline

    If the patient has been administered Flumanezil or Naloxone in either theatre or recovery this increases their risk of adverse complication/event such as respiratory depression/compromise and increase sedation/or altered conscious state. 

    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 Emergency Response Criteria these may include:

    • Patient factors; examples include increased risk of hypothermia including children with Cerebral Palsy or family history of Malignant Hypothermia
    • Surgical factors; examples include major surgery where there has been significant blood loss
    • Social factors; examples include a child with autism who may not be well supervised post-operatively 

    For further information regarding modification on the Emergency Response 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 therapies and interventions being delivered to the child and be consistent with requirements of other individual guidelines and procedures.

    • As per the Observation and Continuous Monitoring clinical guideline, observations should be performed at least once per hour if the patient:
      • Has previous observations within the orange or purple zone of the ViCTOR charts
      • Was transferred from PICU (within last 8 hours or as clinically indicated)
      • Is receiving PCA, Epidural, or Opioid infusion
      • Is receiving an Insulin infusion
      • Has ICP monitoring
      • Note, other children will require hourly observations and continuous monitoring
        Refer to the Observation and Continuous Monitoring clinical guideline for more information 
    • 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
    • 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 the orange or purple zone of the ViCTOR charts this must be addressed prior to transfer
    • Management complications/troubleshooting
    • Education
    • Discharge planning and community-based management 

    Escalation of care

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

    If immediate review is required in a deteriorating child, call a MET (dial 777 and state building, level, ward and room number).

    Companion documents

    Evidence table

    Routine Post Anaesthetic Observation Guideline Evidence Table


    Please remember to read the disclaimer

    The development of this nursing guideline was coordinated by Stacey Richards, Nurse Educator, Undergraduate Nurses, and approved by the Nursing Clinical Effectiveness Committee. Updated  October 2016.