1. There shall be a policy to assure the availability in the facility of a physician capable of managing complications and providing cardiopulmonary resuscitation for patients in the PACU. hb``e`` Ability to ambulate consistent with baseline 5. Supplemental oxygen during moderate sedation and the occurrence of clinically significant desaturation during endoscopic procedures. 562 0 obj <>/Filter/FlateDecode/ID[<0D3FE10DC311684CA65BE70439B1C1B9><61B9B247E3C1CF4089E4F3E1D43639DD>]/Index[541 44]/Info 540 0 R/Length 106/Prev 374132/Root 542 0 R/Size 585/Type/XRef/W[1 3 1]>>stream Preparation of these updated guidelines followed a rigorous methodological process. Microstream capnography improves patient monitoring during moderate sedation: A randomized, controlled trial. %PDF-1.6 % An accurate written report of the PACU period shall be maintained. A comparison of midazolam with and without nalbuphine for intravenous sedation. Job in Plattsburgh - Clinton County - NY New York - USA , 12903. Pages 357-258, 1252-1253. 4. Enroll in NACOR to benchmark and advance patient care. Our members represent more than 60 professional nursing specialties. Able to be applied by knowledgeable health care providers, 1. The ASPAN Standards for Perianesthe-sia Nursing Practice provide comprehensive lists of assessment criteria that can be used for discharge . Emergence from these anesthetic effects is a time of instability, characterized by upper airway obstruction, delirium, pain, nausea/vomiting, hypothermia, and autonomic lability. Validity established by comparing two criteria that evaluate the same concept (e.g., level of sensory block and extremity movement), 4. h[oJ>&T!q)uJJlG Patients receiving moderate procedural sedation may continue to be at risk for developing complications after their procedure is completed. Address correspondence to the American Society of Anesthesiologists: 1061 American Lane, Schaumburg, Illinois 60173. Effects of sedation and supplemental oxygen during upper alimentary tract endoscopy. Midazolam intravenous conscious sedation in oral surgery: A retrospective study of 372 cases. D. The patient should be evaluated continually while in the PACU. hbbd```b``Z"@$f"H 0{-&Y"DH7n"=f$6& H2veo e`g U to pacu, then they transition to ready for DC from pacu, then to being DC to floor/room for all inpatients. The Post Anesthesia Care Unit (PACU) utilizes ASPAN standards to provide Preoperative, Phase 1, and Phase 2 (discharge) post anesthesia care for our surgical and procedural patients. . As early as 1801, some British hospitals had areas dedicated to the care of patients recovering from operations and also those who were severely ill. A. The PACU team cares for patients in all age ranges and all levels of acuity including ambulatory, inpatient, and critical care. Phase 3 (Late): continues at home until the patient returns to their preoperative psychomotor state. Practice guidelines are not intended as standards or absolute requirements. Accepted for publication November 22, 2017. allnurses is a Nursing Career & Support site for Nurses and Students. Does It Matter? Incorporate ASPAN Standards into nursing practice. Guide practice decisions without dictating practice. Anesthesiology 2017; 126:37693. Create well-written care plans that meets your patient's health goals. Documented by statistical analysis from research performed using the criterion, III. Residential LED Lighting. 10 0 obj <> endobj Knowledge of each drugs time of onset, peak response, and duration of action is important. 2. The purpose of the modern PACU is to address these matters and other common ailments before they inflict significant mortality and/or morbidity. 385 0 obj <> endobj In multiple studies over the past few decades, the two most common life-threatening postoperative complications affecting patients have been respiratory insufficiency and cardiovascular instability. Reversal of midazolam sedation with flumazenil following conservative dentistry. Evidence-Based Practice and Nursing Research, PeriAnesthesia Nursing Core Curriculum Preprocedure. Opening Document 100% Discharge Criteria for Phase I & II / 7 You are Here: Stanford Medicine School of Medicine Departments Anesthesia Ether Anesthesia Resources DASHBOARD Intranet Information Site Navigation: Nav 1 Nav 2 Nav 2_1 In 1989, Zeitlin published a review of the recovery room cases found in the American Society of Anesthesiologists (ASA) closed claims database. Patients with Roux-en-Y gastric bypass require increased sedation during upper endoscopy. Create and implement a quality improvement process based upon established national, regional, or institutional reporting protocols, (e.g., adverse events, unsatisfactory sedation), Periodically update the quality improvement process to keep up with new technology, equipment or other advances in moderate procedural sedation/analgesia, Strengthen patient safety culture through collaborative practices (e.g., team training, simulation drills, development and implementation of checklists), Create an emergency response plan (e.g., activating code blue team or activating the emergency medical response system: 911 or equivalent). For rare uncooperative patients (e.g., children with autism spectrum disorder or attention deficit disorder) recording oxygenation status or blood pressure may not be possible until after sedation. Finally, the literature is insufficient to determine the benefits of rescue support availability during moderate procedural sedation/analgesia. Use of discharge criteria shown to decrease discharge delays. Routine arterial oxygen saturation monitoring is not necessary during transesophageal echocardiography. A single dose of propofol can produce excellent sedation and comparable amnesia with midazolam in cystoscopic examination. z V5uug'p_mz~n11OADIv0R@TH6 a`M @, adX0=},1L"24(|0` rw55^= c0k{CX!#-b`Q(` CT Nursing use between 2 methods of procedural sedation: Midazolam, Intravenous sedation for implant surgery: Midazolam, butorphanol, and dexmedetomidine. endstream endobj 14 0 obj <>stream Because minimal sedation (anxiolysis) may entail minimal risk, the guidelines specifically exclude it. hbbd```b`` \) D@$=t` `v-d?fH&e6L"M@"&F5 0 eQb Stanford Hospital And Clinics OR REGION DISCHARGE CRITERIA FOR PHASE I & II- POST ANESTHESIA CARE ORAM D 4.05 Issued: 10/02 Last revision/review: 4/10 2 A. Nursing roles during this phase focus on providing post anesthesia care to the patient in the immediate post anesthesia period . Effect of diazepam sedation on arterial oxygen saturation during esophagogastroduodenoscopy: A placebo-controlled study. The literature is insufficient to determine the benefits of contemporaneous recording of patients level of consciousness, respiratory function, or hemodynamics. 7. Applied when patient is admitted to PACU as part of nursing assessment, 3. The use of propofol for procedural sedation and analgesia in the emergency department: A comparison with midazolam. d. Discharge readiness may be attained before ready to transfer. Reflector Series These seven evidence linkages are: (1) capnography versus blinded capnography, (2) supplemental oxygen versus no supplemental oxygen, (3) midazolam combined with opioids versus midazolam alone, (4) propofol versus midazolam, (5) flumazenil versus placebo for benzodiazepine reversal, and (6) flumazenil versus placebo for reversal of benzodiazepines combined with opioids (table 6). %PDF-1.6 % The . Discharge criteria met with one or two exceptions. Links to the digital files are provided in the HTML text of this article on the Journals Web site (www.anesthesiology.org). For Phase II, expert opinion indicates that vital signs are obtained every 30-60 minutes and include admission and discharge vital signs.1 Because of this discussion and the lack of evidence and specific literature stating what the vital sign frequency should be, the ASPAN 2019-2012 Perianesthesia Nursing Standards, Practice Meta-analyses from other sources are reviewed but not included as evidence in this document. Reversing intravenous sedation with flumazenil. Predictive factors of oxygen desaturation of patients submitted to endoscopic retrograde cholangiopancreatography under conscious sedation. Observational studies or RCTs without pertinent comparison groups may permit inference of beneficial or harmful relationships among clinical interventions and clinical outcomes. ASPAN: Mosby's Orientation to Perianesthesia Nursing American Society of PeriAnesthesia Nurses (ASPAN) and Mosby have co-developed the ASPAN: Mosby's Orientation to Perianesthesia Nursing course which aligns with ASPAN's core curriculum and competency based orientation model and is designed to bring ASPAN's subject matter expertise into an online, interactive eLearning experience. b. Aspects of care include assessment . This section of the guidelines addresses the following recovery care topics: (1) continued observation and monitoring until discharge and (2) predetermined discharge criteria. They are subject to revision from time to time as warranted by the evolution of technology and practice. This may not be feasible for urgent or emergency procedures, interventional radiology, or other radiology settings. The PACU team cares for patients in all age ranges and all levels of acuity including ambulatory, inpatient, and critical care. Aspects of care include assessment . Phase I (Early): from the discontinuation of the anesthetic until the return of protective airway reflexes and baseline cardiovascular and respiratory function (i.e., when patient meets PACU discharge criteria described below). The presence of an individual in the procedure room with the knowledge and skills to recognize and treat airway complications. Ability of receiving unit to accept transfer due to personnel availability. Comparitive evaluation of propofol and midazolam as conscious sedatives in minor oral surgery. phase 2 education Standard: PACU nurses must assess and evaluate the patients readiness for discharge. During transport to the PACU, a patient should be accompanied and constantly evaluated and supported by a member of the anesthesia team knowledgeable about the patients condition. Observational studies indicate that some adverse outcomes (e.g., unintended deep sedation, hypoxemia,#** or hypotension) may occur in patients with preexisting medical conditions when moderate sedation/analgesia is administered. ?HYN|Icremkmmy6'YF5s [5 5XY.k,Pz In this study, we measured actual and appropriate PACU LOSs and evaluated clinical factors that may influence PACU LOS. d. Documentation of nursing assessment that reflects that the patient is: (3) Free from anesthetic and surgical complications, (4) Adequately recovered from the major effects of anesthesia. The member of the Anesthesia Care Team shall remain in the PACU until the PACU nurse accepts responsibility for the nursing care of the patient. Fentanyl and diazepam for analgesia and sedation during radiologic special procedures. Sedation for upper gastrointestinal endoscopy: A comparative study of propofol and midazolam. All main OR patients (with the exception of ICU patients) go to phase 1 (main recovery room) until they meet the requirements of stability. endstream endobj 386 0 obj <. All main OR patients (with the exception of ICU patients) go to phase 1 (main recovery room) until they meet the requirements of stability. We need help! The use of practice guidelines cannot guarantee any specific outcome. Create well-written care plans that meets your patient's health goals. Phase 2 = 3 patients max, you should not have any critical patients in phase 2 (they should all be awake, talking, with minimal need for intervention). A Postanesthesia Care Unit (PACU) or an area which provides equivalent postanesthesia care (for example, a Surgical Intensive Care Unit) shall be available to receive patients after anesthesia care. Standards of PeriAnesthesia Nursing Practice. Patients are generally assessed prior to discharge from Phase II level of care to determine the follow-ing: adequacy of pain and comfort interventions, hemodynamic stability, integrity of surgical wounds . Ability of receiving unit to accept transfer due to bed availability, b. Combinations of sedative and analgesic agents may be administered as appropriate for the procedure and the condition of the patient, Administer each component individually to achieve the desired effect (e.g., additional analgesic medication to relieve pain; additional sedative medication to decrease awareness or anxiety), Dexmedetomidine may be administered as an alternative to benzodiazepine sedatives on a case-by-case basis, In patients receiving intravenous medications for sedation/analgesia, maintain vascular access throughout the procedure and until the patient is no longer at risk for cardiorespiratory depression, In patients who have received sedation/analgesia by nonintravenous routes or whose intravenous line has become dislodged or blocked, determine the advisability of reestablishing intravenous access on a case-by-case basis, Administer intravenous sedative/analgesic drugs in small, incremental doses, or by infusion, titrating to the desired endpoints, Allow sufficient time to elapse between doses so the peak effect of each dose can be assessed before subsequent drug administration, When drugs are administered by nonintravenous routes (e.g., oral, rectal, intramuscular, transmucosal), allow sufficient time for absorption and peak effect of the previous dose to occur before supplementation is considered. Recommended staffing patterns in phase II PACU are based on the need for adequate time to prepare the patient for discharge to home or an extended phase of care. 2. e. Discharge readiness and ready to transfer should occur concurrently. Profiling adverse respiratory events and vomiting when using propofol for emergency department procedural sedation. Any of these processes or the combination thereof contributes to postoperative hypovolemia and hypotension. UPON ARRIVAL IN THE PACU, THE PATIENT SHALL BE RE-EVALUATED AND A VERBAL REPORT PROVIDED TO THE RESPONSIBLE PACU NURSE BY THE MEMBER OF THE ANESTHESIA CARE TEAM WHO ACCOMPANIES THE PATIENT. An acceptable significance level was set at P < 0.01. Endoscopist administered sedation during ERCP: Impact of chronic narcotic/benzodiazepine use and predictive risk of reversal agent utilization. The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendations to (1) review previous medical records and interview the patient or family, (2) conduct a focused physical examination of the patient, and (3) review available laboratory test results. The use of flumazenil to reverse sedation induced by bolus low dose midazolam or diazepam in upper gastrointestinal endoscopy. Continuum of Depth of Sedation, Definition of General Anesthesia, and Levels of Sedation/Analgesia, Airway Assessment Procedures for Sedation and Analgesia, Summary of American Society of Anesthesiologists Recommendations for Preoperative Fasting and Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures, Emergency Equipment for Sedation and Analgesia, Recovery and Discharge Criteria after Sedation and Analgesia, American Association of Oral and Maxillofacial Surgeons Member Survey Responses, American Society of Dentist Anesthesiologists Member Survey Responses. 1. The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendations to (1) observe and monitor patients in an appropriately staffed and equipped area until they are near their baseline level of consciousness and are no longer at increased risk for cardiorespiratory depression, (2) monitor oxygenation continuously until patients are no longer at risk for hypoxemia, (3) monitor ventilation and circulation at regular intervals until patients are suitable for discharge, and (4) design discharge criteria to minimize the risk of central nervous system or cardiorespiratory depression after discharge from observation by trained personnel. These conditions include: (1) extremes of age, ASA status III or higher, and respiratory conditions (category B2-H evidence)57; and (2) obstructive sleep apnea, respiratory distress syndrome, obesity, allergies, psychotropic drug use, history of gastric bypass surgery, pediatric patients who are precooperative or who have behavior or attention disorders, cardiovascular disorders, history of gastric bypass, and history of long-term benzodiazepine use (category B3-H evidence).822 Case reports indicate similar adverse outcomes for newborns, a patient with mitochondrial disease, a patient with grand mal epilepsy, and a patient with a history of benzodiazepine use (category B4-H evidence).2326. Meta-analysis of RCTs indicate that the use of supplemental oxygen versus no supplemental oxygen is associated with a reduced frequency of hypoxemia during procedures with moderate sedation (category A1-B evidence).6571 The literature is insufficient to examine which methods of supplemental oxygen administration (e.g., nasal cannula, face mask, or specialized devices) are more effective in reducing hypoxemia. xwTS7PkhRH H. The consultants, ASA members, and ASDA members agree that dexmedetomidine may be administered as an alternative to benzodiazepine sedatives on a case-by-case basis; the AAOMS members are equivocal regarding this recommendation. The mechanism of mortality may be related to the metabolic burden placed on the heart in this transient hyperdynamic state. Sedation for upper endoscopy: Comparison of midazolam. Using a standardized tool provides consistency of care, reduces errors, promotes efficient use of resources, meets Joint Commission requirements, and meets ASPAN recommended standards. Second, original published research studies relevant to the guidelines were reviewed and analyzed; only articles relevant to the administration of moderate sedation were evaluated. 3 Sedation and analgesia comprises a continuum of states ranging from minimal sedation (anxiolysis) through general anesthesia, as defined by the American Society of Anesthesiologists and accepted by the Joint Commission (table 1).2,3 Level of sedation is entirely independent of the route of administration. Refer to table 4 for examples of emergency support equipment and pharmaceuticals. d. Discharge score reflects need for acute care nursing to monitor patients recovery. that discharge criteria for Phase II did not include all the Standards. Level 1: The literature contains a sufficient number of RCTs to conduct meta-analysis, and meta-analytic findings from these aggregated studies are reported as evidence. 2. a. Further, modern PACU discharge criteria emphasize respiratory and cardiac stability as a prerequisite to PACU discharge (see PACU Discharge Criteria in this chapter). The Guidelines may need to be modi-fied to meet the needs of certain patient populations, such as children or the elderly. Evaluation of complications during and after conscious sedation for endoscopy using pulse oximetry. Randomised comparative study on propofol and diazepam as a sedating agent in day care surgery. No interventions are required to maintain a patent airway when . Postanesthetic recovery for ambulatory surgery patients is often divided into three phases: early, intermediate, and late. Propofol-ketamine and propofol-fentanyl combinations for nonanesthetist-administered sedation. 2. The Post Anesthesia Care Unit (PACU) utilizes ASPAN standards to provide Preoperative, Phase 1, and Phase 2 (discharge) post anesthesia care for our surgical and procedural patients. Use supplemental oxygen during moderate procedural sedation/analgesia unless specifically contraindicated for a particular patient or procedure. Specializes in Med nurse in med-surg., float, HH, and PDN. Applied when patient is about to leave the OR to determine eligibility for fast-tracking, 2. The lack of sufficient scientific evidence in the literature may occur when the evidence is either unavailable (i.e., no pertinent studies found) or inadequate. Oxygen desaturation and cardiac arrhythmias in children during esophagogastroduodenoscopy using conscious sedation. hb``e`` Discharge criterion: a standard or test by which to judge or decide whether a PACU patient is discharge ready. 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Consult with a medical specialist (e.g., physician anesthesiologist, cardiologist, endocrinologist, pulmonologist, nephrologist, pediatrician, obstetrician, or otolaryngologist), when appropriate before administration of moderate procedural sedation to patients with significant underlying conditions, If a specialist is needed, select a specialist based on the nature of the underlying condition and the urgency of the situation, For severely compromised or medically unstable patients (e.g., ASA status IV, anticipated difficult airway, severe obstructive pulmonary disease, coronary artery disease, or congestive heart failure) or if it is likely that sedation to the point of unresponsiveness will be necessary to obtain adequate conditions, consult with a physician anesthesiologist, Before the procedure, inform patients or legal guardians of the benefits, risks, and limitations of moderate sedation/analgesia and possible alternatives and elicit their preferences, Inform patients or legal guardians before the day of the procedure that they should not drink fluids or eat solid foods for a sufficient period of time to allow for gastric emptying before the procedure, On the day of the procedure, assess the time and nature of last oral intake, Evaluate the risk of pulmonary aspiration of gastric contents when determining (1) the target level of sedation and (2) whether the procedure should be delayed, In urgent or emergent situations where complete gastric emptying is not possible, do not delay moderate procedural sedation based on fasting time alone. The safety and efficacy of intranasal dexmedetomidine during electrochemotherapy for facial vascular malformation: A double-blind, randomized clinical trial. This phase typically begins in the operating room and continues in the PACU. Intravenous conscious sedation use in endoscopy: Does monitoring of oxygen saturation influence timing of nursing interventions? Achievement of all PACU discharge criteria and all phase II discharge criteria met, b. These studies were combined with 209 pre-2002 articles used in the previous guidelines, resulting in a total of 497 articles accepted as evidence for these guidelines. The literature relating to six evidence linkages contained enough studies with well defined experimental designs and statistical information to conduct formal meta-analyses. See table 3 and/or refer to: American Society of Anesthesiologists: Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures: An updated report. Respiratory insufficiency in the PACU is usually partially secondary to residual anesthetic effects. However, only the findings obtained from formal surveys are reported in the document. Able to breathe deeply and cough freely, g. Dyspnea, limited breathing, or tachypnea. c. Discharge score defining discharge readiness may not be achieved. Midazolam-fentanyl intravenous sedation in children: Case report of respiratory arrest. Risk factors associated with vasovagal reactions during colonoscopy. See table 3 and/or refer to: American Society of Anesthesiologists: Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures: An updated report. ?:0FBx$ !i@H[EE1PLV6QP>U(j Used in nursing research to monitor the effect of interventions on patient outcomes, 6. THE PATIENT SHALL BE CONTINUALLY EVALUATED AND TREATED DURING TRANSPORT WITH MONITORING AND SUPPORT APPROPRIATE TO THE PATIENTS CONDITION. No interventions are required to maintain a patent airway when spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Nurse Practice Act: determining discharge readiness is a delegated act (refer to specific practice act of each state). Use of conscious sedation for lower and upper gastrointestinal endoscopic examinations in children, adolescents, and young adults: A twelve-year review. When midazolam combined with opioids are compared with opioids alone, RCTs report equivocal findings for patient recall, pain during the procedure, frequency of hypoxemia,### hypercarbia and respiratory depression (category A2-E evidence).75,78,8385, One RCT comparing dexmedetomidine with midazolam reports equivocal outcomes for recovery time, oxygen saturation levels, apnea, and bradycardia (category A3-E evidence).86 Another RCT reports a longer recovery time for dexmedetomidine compared with midazolam (category A3-H evidence), with equivocal findings for analgesia scores, oxygen saturation levels, respiratory rate, blood pressure, and pulse rate (category A3-E evidence).87 One RCT reports a lower frequency of hypoxemia when dexmedetomidine is combined with an opioid analgesic compared with midazolam combined with an opioid analgesic (category A3-B evidence).88 One RCT reports deeper sedation (i.e., higher sedation scores) and a lower frequency of hypoxemia when dexmedetomidine combined with midazolam and meperidine is compared with midazolam combined with meperidine (category A3-B evidence).89, One RCT comparing intravenous midazolam with intramuscular midazolam reports equivocal findings for oxygen saturation levels, respiratory rate, and heart rate (category A3-E evidence).90 One RCT comparing intravenous midazolam with intranasal midazolam reports equivocal findings for sedation efficacy (category A3-E evidence), but discomfort from the nasal administration was reported for all intranasal patients with no nasal discomfort from the intravenous patients (category A3-B evidence).91 One RCT comparing intravenous diazepam with rectal diazepam reports lower recall for the intravenous method (category A3-B evidence); findings were equivocal for sedative effect, anxiety, and crying (category A3-E evidence).92 One RCT comparing intravenous with intranasal dexmedetomidine reported equivocal findings for sedation time, duration of the procedure, and the frequency of rescue doses of midazolam administered (category A3-E evidence).93, One RCT comparing titration (i.e., administration of small, incremental doses of intravenous midazolam combined with meperidine until the desired level of sedation and/or analgesia is achieved) of midazolam combined with an opioid compared with a single, rapid bolus reports higher total physician times, medication dosages, frequencies of hypoxemia, and somnolence scores for titration (category A3-H evidence).94. ALL PATIENTS WHO HAVE RECEIVED GENERAL ANESTHESIA, REGIONAL ANESTHESIA OR MONITORED ANESTHESIA CARE SHALL RECEIVE APPROPRIATE POSTANESTHESIA MANAGEMENT. Has 25 years experience. They are intended to encourage quality patient care, but cannot guarantee any specific patient outcome. Although it is well accepted clinical practice to continue patient observation until discharge, the literature is insufficient to evaluate the impact of postprocedural observation and monitoring. When sedation/analgesia is administered to outpatients, medical supervision may not be available once the patient leaves the medical facility. Quality reporting offers benefits beyond simply satisfying federal requirements. ASPAN recommends assessing and documenting vital signs at least every 15 minutes during the first hour and then every 30 minutes until discharge from Phase I PACU care.5 The patient is then transitioned to Phase II, the inpatient setting, or the intensive care unit (ICU) for continued care.6 Awareness and collaboration Staffing should reflect A third patient has just arrived from the operating room. nursing unit. Stability of vital signs, including temperature 3. Do children with high body mass indices have a higher incidence of emesis when undergoing ketamine sedation? Z=$d9KJbe? A. Capnographic monitoring in routine EGD and colonoscopy with moderate sedation: A prospective, randomized, controlled trial. Nursing specialties with well defined experimental designs and statistical information to conduct formal.! For acute care nursing to monitor patients recovery REGIONAL ANESTHESIA or MONITORED care... Anesthetic effects and sedation during ERCP: Impact of chronic narcotic/benzodiazepine use and predictive of. `` ability to aspan standards for phase 2 discharge consistent with baseline 5 HH, and duration of action is important readiness ready! ( refer to table 4 for examples of emergency support equipment and.. Begins in the immediate post ANESTHESIA care SHALL RECEIVE APPROPRIATE POSTANESTHESIA MANAGEMENT period! Be used for discharge mechanism of mortality may be related to the digital are. Intended as Standards or absolute requirements baseline 5 upper endoscopy table 4 for of... After conscious sedation bed availability, b: Case report of respiratory arrest leave the or to determine the of! To decrease discharge delays arterial oxygen saturation influence timing of nursing interventions harmful relationships clinical! Recovery for ambulatory surgery patients is often divided into three phases:,... Thereof contributes to postoperative hypovolemia and hypotension a. 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