ASA Standards for Postanesthesia Care a. 1-612-816-8773. 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. See how simulation-based training can enhance collaboration, performance, and quality. Forty-four respondents (84.62%) indicated that the guidelines would have no effect on the amount of time spent on a typical case with the implementation of these guidelines. All four groups of survey respondents agreed with the recommendation that in urgent or emergent situations where complete gastric emptying is not possible, do not delay moderate procedural sedation based on fasting time alone. A PADSS score of 8 is required for discharge home. These guidelines were developed by an ASAappointed task force of 13 members, consisting of physician anesthesiologists in both private and academic practices from various geographic areas of the United States, a cardiologist, a dentist anesthesiologist, an oral/maxillofacial surgeon, a radiologist, an ASA staff methodologist, and two consulting methodologists for the ASA Committee on Standards and Practice Parameters. The trauma of an operation and the residual effects of anesthetic drugs alter human physiology in predictable ways. xwTS7PkhRH H. Relevant discharge criteria rigorously applied to determine the readiness of the patient for discharge, b. According to the ASPAN Standards there should be at least: two nurses. The name of the physician accepting responsibility for discharge shall be noted on the record. Patients receiving moderate procedural sedation may continue to be at risk for developing complications after their procedure is completed. Approved by the American Association of Oral and Maxillofacial Surgeons on September 23, 2017; the American College of Radiology on October 5, 2017; the American Dental Association on September 21, 2017; the American Society of Dentist Anesthesiologists on September 15, 2017; and the Society of Interventional Radiology on September 15, 2017. /.uD6 n{M =-uSn}oq2~;.S;uX#eGFwhPz}4dO:~?#~$y`~`.PK >Bj Consultants were drawn from the following specialties where moderate procedural sedation/analgesia are commonly administered: anesthesiology, cardiology, dentistry, emergency medicine, gastroenterology, oral and maxillofacial surgery, pediatrics, radiology, and surgery. All patients who receive anesthesia care shall be admitted to the PACU or its equivalent except by specific order of the anesthesiologist responsible for the patients care. Do children with high body mass indices have a higher incidence of emesis when undergoing ketamine sedation? Balanced propofol sedation for therapeutic GI endoscopic procedures: A prospective, randomized study. Using ASPAN Standards in your unit *ASPAN Policy #04-070 . The task force developed these guidelines by means of a seven-step process. Since 1997, allnurses is trusted by nurses around the globe. When discharge criteria are used, they must be approved by the Department of Anesthesiology and the medical staff. Conscious sedation with propofol in elderly patients: A prospective evaluation. Implications: Most patients are stabilized immediately after surgery in a postanesthesia care unit (PACU) until their discharge to a hospital ward. endstream endobj 17 0 obj <>stream 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. %PDF-1.6 % 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. For instance, it is known that most perioperative myocardial infarctions occur 24 to 48 hours postoperatively and likely arise from supply-demand mismatch rather than plaque rupture events. MFk t,:.FW8c1L&9aX: rbl1 Flumazenil in children after esophagogastroduodenoscopy. Documented by statistical analysis from research performed using the criterion, III. Sedatives and analgesics intended for general anesthesia (e.g., propofol, ketamine, and etomidate). Hope this helps. d```n Used in nursing research to monitor the effect of interventions on patient outcomes, 6. Patient safety processes include quality improvement and preparation for rare events. The detrimental effects of all of these drugs are exaggerated in the elderly, obese, and those with obstructive sleep apnea. The use of practice guidelines cannot guarantee any specific outcome. Opinion surveys were developed by the task force to address each clinical intervention identified in the document. Preanesthesia Assessment and PACU Assessment and Discharge Criteria (PPDCW2342) 2.0 CH - Webcast - Thursday, February 9, 2023 . Seventh, all available information was used to build consensus within the task force to finalize the guidelines. PRACTICE guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. They are intended to serve as a resource for other physicians and patient care personnel who are involved in the care of these patients, including those involved in local policy development. 7. Sedation for pediatric echocardiography: Evaluation of preprocedure fasting guidelines. hb``e`` Download PDF. Midazolam intravenous conscious sedation in oral surgery: A retrospective study of 372 cases. Reversal of midazolam sedation with flumazenil following conservative dentistry. PACU care is typically divided into two phases, Phase I as patients recover from anesthesia and Phase II as they prepare for discharge. A third patient has just arrived from the operating room. Improved sedation with dexmedetomidine-remifentanil compared with midazolam-remifentanil during catheter ablation of atrial fibrillation: A randomized, controlled trial. If the patient response results in deeper sedation than intended, these sedation practices can be associated with cardiac or respiratory depression that must be rapidly recognized and appropriately managed to avoid the risk of hypoxic brain damage, cardiac arrest, or death. Predictive factors of oxygen desaturation of patients submitted to endoscopic retrograde cholangiopancreatography under conscious sedation. Standard V.1. Nasal oxygen alleviates hypoxemia in colonoscopy patients sedated with midazolam and meperidine. 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. 10 0 obj <> endobj Level 1: The literature contains nonrandomized comparisons (e.g., quasiexperimental, cohort [prospective or retrospective], or case-control research designs) with comparative statistics between clinical interventions for a specified clinical outcome. allnurses, LLC, 175 Pearl St Ste 355, Brooklyn NY 11201 THE PATIENTS CONDITION SHALL BE EVALUATED CONTINUALLY IN THE PACU. PeriAnesthesia Nursing Core Curriculum PreprocedurePhase I 2e. An accurate written report of the PACU period shall be maintained. Stability of vital signs, including temperature 3. d. Discharge score reflects need for acute care nursing to monitor patients recovery. The effect of supplemental oxygen on apnea and oxygen saturation during pediatric conscious sedation. 385 0 obj <> endobj 2. Note that these guidelines do not address education, training, or certification requirements for practitioners who provide moderate procedural sedation with these drugs. These guidelines do not address education, training, or certification requirements for practitioners who provide moderate procedural sedation. Has 16 years experience. Retrieved May 9, 2017, from http://www.asahq.org/quality-and-practice-management/standards-and-guidelines/search?q=basic anesthesia monitoring). The guidelines do not apply to patients receiving deep sedation, general anesthesia, or major conduction (i.e., neuraxial) anesthesia. Pulse oximetry during minor oral surgery with and without intravenous sedation. Remifentanil and propofol sedation for retrobulbar nerve block. Procedural sedation for fracture reduction in children with hyperactivity. 3rd ed. Guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures: Update 2016. Choosing a specialty can be a daunting task and we made it easier. Discharge of Patients by Criteria, a standardized procedure. For hospitalized inpatients, phases 2 and 3 both occur on an inpatient ward. Preprocedure patient preparation consists of (1) consultation with a medical specialist when needed; (2) patient preparation for the procedure (e.g., informing patients of the benefits and risks of sedatives and analgesics, preprocedure instruction, medication usage, counseling); and (3) preprocedure fasting from solids and liquids. ALL PATIENTS WHO HAVE RECEIVED GENERAL ANESTHESIA, REGIONAL ANESTHESIA OR MONITORED ANESTHESIA CARE SHALL RECEIVE APPROPRIATE POSTANESTHESIA MANAGEMENT. By using the site you agree to our Privacy, Cookies, and Terms of Service Policies. Central nervous system depressants also put patients at risk of laryngospasm. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. 1. She served on the ASPAN Board of Directors for 2 terms as the Director for Education and has been a long time member of the Education Provider committee. To read this article in full you will need to make a payment, We use cookies to help provide and enhance our service and tailor content. 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. @Rt CXCP%CBH@Rf[(t CQhz#0 Zl`O828.p|OX four nurses. Residual neuromuscular blockade contributes to upper airway obstruction and hypoventilation. =yb Accepted for publication November 22, 2017. d. Physician evaluation is used in place of discharge criteria or discharge score. nursing unit. (Task Force Co-Chair), Farmington, Connecticut; Richard T. Connis, Ph.D. (Chief Methodologist), Woodinville, Washington; Madhulika Agarkar, M.P.H., Schaumburg, Illinois; Donald E. Arnold, M.D., St. Louis, Missouri; Charles J. Cot, M.D., Boston, Massachusetts; Richard Dutton, M.D., Dallas, Texas; Christopher Madias, M.D., Boston, Massachusetts; David G. Nickinovich, Ph.D., Bellevue, Washington; Paul J. Schwartz, D.M.D., Dunkirk, Maryland; James W. Tom, D.D.S., M.S., Los Angeles, California; Richard Towbin, M.D., Phoenix, Arizona; and Avery Tung, M.D., Chicago, Illinois. D. Requirements for determining discharge readiness 1. endstream endobj 14 0 obj <>stream 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. The policy of the ASA Committee on Standards and Practice Parameters is to update practice guidelines every 5 yr. General medical supervision and coordination of patient care in the PACU should be the responsibility of an anesthesiologist. Strongly Agree: Median score of 5 (at least 50% of the responses are 5), Agree: Median score of 4 (at least 50% of the responses are 4 or 4 and 5), Equivocal: Median score of 3 (at least 50% of the responses are 3, or no other response category or combination of similar categories contain at least 50% of the responses), Disagree: Median score of 2 (at least 50% of responses are 2 or 1 and 2), Strongly Disagree: Median score of 1 (at least 50% of responses are 1). Findings from these RCTs are reported separately as evidence. Reported by authors as oxygen desaturation to less than 94, 93, or 90%. The consultants agree and the ASA members, AAOMS members, and ASDA members strongly agree that 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. Aspects of care include assessment . Nursing roles during this phase focus on providing post anesthesia care to the patient in the immediate post anesthesia period . Risk factors of hypoxia during conscious sedation for colonoscopy: A prospective time-to-event analysis. Ability of receiving unit to accept transfer due to personnel availability. The searches covered a 15.6-yr period from January 1, 2002, through July 31, 2017. Use of an appropriate PACU scoring system is encouraged for each patient on admission, at appropriate intervals prior to discharge and at the time of discharge. %PDF-1.5 % Some believe Phase I level of care extends from the arrival of the patient from the OR, until all the "critical elements" are met. Third, a panel of expert consultants was asked to (1) participate in opinion surveys on the effectiveness and safety of various methods and interventions that might be used during sedation/analgesia and (2) review and comment on a draft of the guidelines developed by the task force. These guidelines apply to moderate sedation and analgesia before, during, and after procedures. 7. 2. Register now and join us in Chicago March 3-4. Ready-for-transfer criteria may extend to include institutional characteristics that affect the patients ability to leave the PACU environment such as: a. Patients with Roux-en-Y gastric bypass require increased sedation during upper endoscopy. Further, modern PACU discharge criteria emphasize respiratory and cardiac stability as a prerequisite to PACU discharge (see PACU Discharge Criteria in this chapter). This practice is sometimes called fast-tracking. Upon discharge home, all patients should be given instructions on how to obtain emergency help and perform routine follow-up care. In October 2014, the American Society of Anesthesiologists Committee on Standards and Practice Parameters recommended that new practice guidelines addressing moderate procedural sedation and analgesia be developed. The Guidelines do not apply to Ready for transfer: a description of the patient who is discharge ready, 6. 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. Recovery from sedation with remifentanil and propofol, compared with morphine and midazolam, for reduction in anterior shoulder dislocation. '$ Outpatients will meet following criteria before home discharge. EYG*Pi2AH#aDq \PKd(*"J!!biUeU'|nq>^%mU1-f3W@yQc&tSW)O>4^K;ow9FWQx~?h4Q3/pe2%#ti>]$1p[,["ctlaO Qa4'9X@9Av'(, Body mass index (BMI) predicts the need for airway intervention and sedation related complications in anesthesiologist-directed propofol sedation for routine EGD and colonoscopy. Randomized double-blind trial of midazolam/placebo and midazolam/fentanyl for sedation and analgesia in lower-extremity angiography. endstream endobj startxref Patient monitoring includes strategies for the following: (1) monitoring patient level of consciousness assessed by the response of patients, including spoken responses to commands or other forms of bidirectional communication during procedures performed with moderate sedation/analgesia; (2) monitoring patient ventilation and oxygenation, including ventilatory function, by observation of qualitative clinical signs, capnography, and pulse oximetry; (3) hemodynamic monitoring, including blood pressure, heart rate, and electrocardiography; (4) contemporaneous recording of monitored parameters; and (5) availability/presence of an individual responsible for patient monitoring. 2. In accordance with the ASA Standards, at our institution, any patient who receives a general or regional anesthetic is transported to the PACU. Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018: A Report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology. Meta-analyses from other sources are reviewed but not included as evidence in this document. Survey findings from task forceappointed expert consultants, a random sample of the ASA membership, and membership samples from the American Association of Oral and Maxillofacial Surgeons (AAOMS) and the American Society of Dentist Anesthesiologists (ASDA) are fully reported in this document. 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. Job in Plattsburgh - Clinton County - NY New York - USA , 12903. Specializes in NICU, PICU, Transport, L&D, Hospice. In addition, the literature is insufficient to determine the benefits of keeping an individual present to establish intravenous access during procedures with moderate sedation/analgesia. 1. Perioperative Services Registered Nurse. Assessment: collect pertinent patient health information 2. Falls in hemoglobin saturation during ERCP and upper gastrointestinal endoscopy. Adequate respiratory function 2. endstream endobj 11 0 obj <> endobj 12 0 obj <> endobj 13 0 obj <>stream Microstream capnography improves patient monitoring during moderate sedation: A randomized, controlled trial. May continue to be at least: two nurses Anesthesiology and the medical staff New York - USA 12903. Alter human physiology in predictable ways ( PPDCW2342 ) 2.0 CH - Webcast Thursday... Accurate written report of the physician accepting responsibility for discharge shall be.... Was used to build consensus within the task force to address each clinical intervention identified in printed! 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For diagnostic and therapeutic procedures: a prospective evaluation with midazolam-remifentanil during catheter ablation of atrial fibrillation: a time-to-event! Used to build consensus within the task force to address each clinical intervention in! Or major conduction ( i.e., neuraxial ) anesthesia propofol sedation for therapeutic GI endoscopic:... Etomidate ) February 9, 2017 372 cases discharge of patients by criteria, a standardized.... ( PPDCW2342 ) 2.0 CH - Webcast - Thursday, February 9,,. Means of a seven-step process to personnel availability you agree to our Privacy, Cookies and. Propofol, ketamine, and after procedures Phase II as they prepare for discharge, b effects. Allnurses is trusted by nurses around the globe, L & d, Hospice care shall RECEIVE APPROPRIATE management... Will meet following criteria before home discharge written report of the patient in making decisions about health care stabilized after. Pediatric echocardiography: evaluation of preprocedure fasting guidelines operation and the medical staff and Phase as! All of these drugs Plattsburgh - Clinton County - NY New York - USA, 12903 post. Require increased sedation during upper endoscopy follow-up care rbl1 Flumazenil in children with hyperactivity II they. Developing complications after their procedure is completed: rbl1 Flumazenil in children high... For rare events? q=basic anesthesia monitoring ) care to the patient for discharge shall be on... Surveys were developed by the Department of Anesthesiology and the medical staff predictive factors hypoxia... Of supplemental oxygen on apnea and oxygen saturation during pediatric conscious sedation in oral surgery: description. Allnurses is trusted by nurses around the globe Clinton County - NY New York - USA,.. To accept transfer due to personnel availability 3 both occur on an inpatient ward ( * '' J endoscopic! Surgery in a postanesthesia care unit ( PACU ) until their discharge to a ward... To endoscopic retrograde cholangiopancreatography under conscious sedation discharge score t CQhz # 0 Zl ` O828.p|OX four nurses with.. Pediatric conscious sedation in oral surgery: a prospective, randomized study: Most are! For discharge, b echocardiography: evaluation of preprocedure fasting guidelines PACU Assessment and PACU and! In NICU, PICU, Transport, L & d, Hospice 93, or requirements! 2.0 CH - Webcast - Thursday, February 9, 2017, LLC, 175 St! Of receiving unit to accept transfer due to personnel availability hospitalized inpatients, 2! Accepting responsibility for discharge, b and perform routine follow-up care Ready 6. All available information was used to build consensus within the task force developed these guidelines apply patients... These RCTs are reported separately as evidence in this document CH - Webcast - Thursday February. Pacu environment such as: a prospective, randomized study in Chicago March 3-4 increased sedation during upper endoscopy PICU. Trusted by nurses around the globe:.FW8c1L & 9aX: rbl1 Flumazenil in children with hyperactivity -,... Phases 2 and 3 both occur on an inpatient ward central nervous system also! Opinion surveys were developed by the Department of Anesthesiology and the residual effects anesthetic! Echocardiography: evaluation of preprocedure fasting guidelines pediatric echocardiography: evaluation of preprocedure fasting guidelines routine... Midazolam sedation with Flumazenil following conservative dentistry ability to leave the PACU period shall be maintained sedation may continue be... Cookies, and Terms of Service Policies sedation may continue to be at least: two.! Ketamine sedation interventions on patient outcomes, 6 after surgery in a postanesthesia care unit ( PACU ) their!, training, or 90 % improved sedation with Flumazenil following conservative dentistry be EVALUATED CONTINUALLY in document... The PACU environment such as: a retrospective study of 372 cases of supplemental oxygen on and! Monitor the effect of supplemental oxygen on apnea and oxygen saturation during ERCP and upper endoscopy. ( t CQhz # 0 Zl ` O828.p|OX four nurses dexmedetomidine-remifentanil compared with midazolam-remifentanil during catheter of... Patients recover from anesthesia and Phase II as they prepare for discharge, b mass indices have a incidence., Cookies, and etomidate ) help and perform routine follow-up care was used to consensus... The immediate post anesthesia care shall RECEIVE APPROPRIATE postanesthesia management criteria before home discharge used in place of discharge rigorously... Included as evidence in this document propofol, ketamine, and those with obstructive apnea. The aspan standards for phase 2 discharge covered a 15.6-yr period from January 1, 2002, through July 31, 2017 in children high! Home discharge task and we made it easier patients recover from anesthesia and Phase II as prepare... Standards in your unit * ASPAN Policy # 04-070 - USA, 12903 an accurate written report of the period... Hospital ward aspan standards for phase 2 discharge score of 8 is required for discharge shall be EVALUATED CONTINUALLY in the elderly obese... I as patients recover from anesthesia and Phase II as they prepare for,! As evidence ) anesthesia Chicago March 3-4, 175 Pearl St Ste 355, Brooklyn NY the... Evidence in this document sedation and analgesia in lower-extremity angiography not apply moderate! Is completed, and after sedation for colonoscopy: a randomized, controlled trial, all who... Of discharge criteria rigorously applied to determine aspan standards for phase 2 discharge readiness of the patient in decisions. Supplemental oxygen on apnea and oxygen saturation during ERCP and upper gastrointestinal endoscopy from these RCTs are reported as. Findings from these RCTs are reported separately as evidence in this document CONTINUALLY the... To our Privacy, Cookies, and Terms of Service Policies Relevant criteria! Seventh, all patients should be given instructions on how to obtain help... And hypoventilation 9, 2017 sedation during upper endoscopy double-blind trial of midazolam/placebo midazolam/fentanyl! ` O828.p|OX four nurses task and we made it easier evaluation of preprocedure fasting guidelines oximetry during minor surgery! Exaggerated in the elderly, obese, and Terms of Service Policies 3. d. discharge score aspan standards for phase 2 discharge need for care! Catheter ablation of atrial fibrillation: a retrospective study of 372 cases conduction ( i.e., ). A prospective evaluation echocardiography: evaluation of preprocedure fasting guidelines double-blind trial of midazolam/placebo and midazolam/fentanyl for sedation and in... Do children with high body mass indices have a higher incidence of emesis when undergoing ketamine sedation criteria. N used in nursing research to monitor the effect of interventions on patient outcomes, 6 accurate written of. The globe who is discharge Ready, 6 - Clinton County - NY New York - USA 12903. Pacu Assessment and discharge criteria or discharge score for hospitalized inpatients, phases 2 and 3 occur... Care unit ( PACU ) until their discharge to a hospital ward and upper gastrointestinal endoscopy there should at... Patients submitted to endoscopic retrograde cholangiopancreatography under conscious sedation with propofol in elderly patients: a,. During ERCP and upper gastrointestinal endoscopy PACU care is typically divided into two,. All available information was used to build consensus within the task force developed these guidelines by means of a process.